Newzealand

Health Needs
Assessment
for New Zealand
Background paper
and literature review
Gregor Coster
Disclaimer
The views expressed within this document are those of the author
and do not necessarily reflect the views of the Minister of Health or
the Ministry of Health.
Published in December 2000 by

Ministry of Health
PO Box 5013, Wellington, New Zealand
ISBN 0-478-23998-X (Book)
ISBN 0-478-23999-8
(Internet)
This document is available on the Ministry of Healths Web
site: http://www.moh.govt.nz
Foreword
The Minister of Health introduced the New Zealand Health and Disability Bill
into Parliament in August 2000, enacted in December 2000. The new Act will
provide for District Health Boards, whose responsibilities will include the requirement to
conduct health needs assessments in their districts.
The Ministry of Health and the Health Funding Authority have been working
collaboratively through the District Health Board Establishment Support Unit to prepare
the way for the transition of Hospital and Health Services to District Health
Boards.
Health needs
assessments will enable those Boards to assess community need in a way that ensures
the health needs of communities are understood and prioritised according to the
availability of resources to meet those needs.
In preparation for the District Health Boards health needs assessments work programme,
the Ministry of Health has commissioned Professor Gregor Coster of the Division of
General Practice and Primary Health Care, University of Auckland, to prepare
a background paper and international literature review on the topic of health
needs assessment, including disability support services. Accompanying this review will
be more specific guidance to District Health Boards on the content of health needs
assessments.
The Ministry anticipates that this review will assist District Health Boards and others in
the sector with health needs assessment.
Ministry of Health
16 October 2000
Health Needs Assessment for New Zealand
iii
Acknowledgements
The author would like to thank the Ministry of Health for the opportunity to prepare
this report. Thanks are due to Nicholas Mays, Chip Cangialose, Philip Davies, Mark
Booth, Martin Tobias, Stephen Buetow and Heather Coster, who kindly reviewed an earlier
draft of the report and provided helpful comments.
The assistance of Stuart Cretney, Librarian at the Ministry of Health in Wellington, and
that of the librarians of the Health Funding Authority, in searching for various references,
is also acknowledged.
The author acknowledges with thanks the kind permission given by Dr Fran McGrath of
the Ministry of Health, and members of the Porirua and Kapiti Healthlinks Health and
Disability Services Integration Project, for access to an early draft of their report
published in September 2000.
Diane Nicholson is thanked for typing assistance. The author accepts full responsibility
for any errors within this report.
iv
Contents
Foreword
iii
Acknowledgements
iv
Executive Summary
Chapter 1: Introduction
1
1.1
Background
1
1.2
Structure
Chapter 2: Health Care Needs Assessment
2.1
Introduction
2.2
Context of health needs assessment
2.3
Purpose and objectives of health needs assessments
2.4
Global approach to health needs assessment

2.4.1 Introduction
2.4.2 Relationship between global health needs assessment, the New Zealand
Health Strategy and purchasing
2.4.3 Characteristics of a global approach
9
9
9
10
2.5
Community-based approaches to health needs assessment

2.5.1 Primary care approaches
2.5.2 Community-orientated primary care approaches (COPC)
2.5.3 Community development approach
2.5.4 Rapid appraisal approaches
2.5.5 Rapid assessment approaches
2.5.6 Other methods for community-based needs assessment
13
14
18
20
20
23
23
2.6
Epidemiologically-based approach to needs assessment

2.6.1 Components of epidemiologically-based approaches to needs
assessments
2.6.2 Conclusion
25
2.7
Comparative approach to needs assessment
29
2.8
Corporate approach to needs assessment
30
2.9
Assessing the methods
31
2.10
Implementation issues
33
26
29
Chapter 3: Prioritisation Stage of Health Needs Assessment

35
3.1
Background
3.1.1 The National Health Committee
3.1.2 Midland Health (199798)
35
36
38
3.2
Health Funding Authority prioritisation process
38
3.3
National Health Committee review of the HFA process
39
3.4
Programme budgeting and marginal analysis

3.4.1 Introduction
3.4.2 The PBMA method
42
42
43
3.5
Community consultation
3.5.1 Observations on the legislative framework
3.5.2 The HFA approach to consultation a tool for DHBs
3.5.3 Consultation with Mori
3.5.4 Consulting the public about health service priorities general comments
48
48
49
51
51
Chapter 4: Case Studies in Health Needs Assessment

54 4.1
Porirua City Health and Disability Report and Plan

54
4.2
Renal disease
57
4.3
Economics, public health and health care purchasing: the Tayside experience of
programme budgeting and marginal analysis
4.3.1 Traditional methods of needs assessment
4.3.2 Programme budget matrix
4.3.3 The views of professionals
4.3.4 The views of parents
4.3.5 Review of research evidence on effectiveness and cost-effectiveness
4.3.6 Priorities for purchasing in child health
4.3.7 Outcome of the child health strategy
59
60
60
65
66
66
66
67
Rapid appraisal in an urban setting: an example from the developed world
68
4.4
Chapter 5: New Zealand Context and Experiences

71 5.1
New Zealand Public Health and Disability Bill

71
5.2
The New Zealand Health Strategy
73
5.3
Placing health needs assessment policy into action
75
5.4
The Treaty of Waitangi
77
5.5
The Treaty of Waitangi from a social perspective
79
5.6
The significance of the Treaty of Waitangi for the health of Mori
80
5.7
Health needs assessment and Mori
82
5.8
New Zealand experiences with health needs assessment

5.8.1 Area Health Boards
5.8.2 Core Services Committee
5.8.3 Regional Health Authorities (RHAs)
5.8.4 Health Funding Authority
5.8.5 District Health Board health needs assessment in New Zealand
5.8.6 Summary
84
84
84
85
86
86
86
Chapter 6: Best Practice In Health Needs Assessment

87 6.1
Introduction
87
6.2
Approach, methods and content

6.2.1 Stakeholders
6.2.2 Objectives
6.2.3 Approach and methods
87
87
87
88
vi
6.2.4
6.2.5
Engagement with Mori

Prioritisation
88
88
6.3
Structural support
6.3.1 Resources
6.3.2 Skill sets
6.3.3 Data
88
88
89
89
6.4
Implementation
90
6.5
Conclusion
90
Chapter 7: Concepts of Need
91
7.1
Introduction
91
7.2
Need for health care
92
7.3
Interpretation of need
93
7.4
Demand
93
7.5
Supply
94
7.6
Need, demand and supply
94
Appendix 1: The Treaty of Waitangi
97
Appendix 2: District Health Boards, Populations and Geographical Areas
99
Appendix 3: Sources of Health Information
101
Appendix 4: Service and Treatment Areas for Health Needs Assessments

Internationally
104
Appendix 5: Health Needs Assessments Conducted by the Ministry of Health and the
Health Funding Authority and Predecessors over the Decade, 19912000
113
References
126
Bibliography
143
vii
List of Tables
Table 1:
Trends in health expenditure, 19942001
Table 2:
Setting objectives for needs assessment exercises
Table 3:
Relationship between task and activity in health needs assessment
10
Table 3:
Methods that supplement community health needs assessment
24
Table 5:
Two hypothetical models of care (eg, for coronary heart disease),

showing level of interest for purchasers
28
Table 6:
Groupings of models of care
28
Table 7:
Specialty-based contracting
43
Table 8:
Programme budgeting
43
Table 9:
Approaches to consultation on health care priorities
52
Table 10:
Numbers and standardised rates of avoidable hospitalisations per 10,000 1994

98
55
Table 11:
Actions agreed
56
Table 12:
Actions recommended
57
Table 13:
Programme budget matrix for the Child Health Strategy in Tayside
63
Table 14:
Top 10 suggested areas for service development and resource release,

ranked by frequency of mention
65
Table A1:
District Health Boards, populations and geographical areas
99
Table A2:
Sources of health information in New Zealand by type, information and

reference source
102
Service and treatment areas for health needs assessments

internationally
105
Table A3:
viii
List of Figures
Figure 1:
Conceptual structure for the District Health Board purchasing process
Figure 2:
The COPC cycle
20
Figure 3:
Information pyramid constructed for rapid participatory appraisal
22
Figure 4:
Contributions to the corporate view of local service needs
30
Figure 5:
The seven steps in the process
39
Figure 6:
A strategic framework for determining purchasing priorities
46
Figure 7:
Health needs assessment rationale (policy)
76
Figure 8:
Health needs assessment and change
77
Figure 9:
The gap in health outcomes between Mori and non-Mori
82
Figure 10:
Interrelationship between need, supply and demand
95
List of Boxes
Box 1:
Core practice data
14
Box 2:
Data from hospitals, community health service providers and the census
16
Box 3:
Focus groups
17
Box 4:
Areas for questionnaire surveys
18
Box 5:
The technique of rapid appraisal
21
Box 6:
Methods of public consultation
52
Box 7:
Goals for the pattern of provision of child health services in Tayside by

2005
59
Priorities for purchasing in child health in Tayside: main

recommendations to the Health Board with examples of specific
changes identified
67
Box 8:
ix
Executive Summary
The New Zealand Public Health and Disability Bill sets out, among other objectives,
the requirement for District Health Boards to improve, promote and protect the health of
people and communities in New Zealand. Boards are required regularly to investigate,
assess and monitor the health status, and the need for services, of their resident
populations. Health needs assessments are a significant part of that process.
Much research has been conducted into the socioeconomic determinants of health, yet
the disparities in health continue for Mori and those with poor socioeconomic status.
The National Health Committee has been addressing issues to do with health need and
the prioritisation of health service provision since its inception in March 1992.
Prioritisation was initially considered through a range of core services, an approach later
modified to the use of best-practice clinical guidelines for health services. The
Committee subsequently critiqued the proposal by the Health Funding Authority to use
programme budgeting and marginal analysis coupled with a principles-based approach.
Need refers to the capacity to benefit. Health need refers to the broader environment
of individual health and encompasses questions of deprivation and inequality, related to
the socioeconomic determinants of health. Meeting health need is a responsibility of
several sectors and not just that of the health sector alone. The term health care need
can be used to describe a populations need for provision of particular health care
services. In an analysis of the resources necessary for the effective provision of health
care, health care needs assessment not only reflects the prevalence or incidence of the
condition or disease state concerned, but also the number of individuals likely to benefit
from treatment, who want treatment, and for whom treatment is generally regarded as a
reasonable investment for a publicly funded health service. This clearly involves a process
of prioritisation.
Health care needs assessment for the purposes of this report is defined as the assessment
of the populations capacity to benefit from health care services, prioritised according
to effectiveness, including cost-effectiveness, and funded within available
resource. Prioritisation is part of the process of health care needs assessment. The
process of prioritisation will result in resource shifting and also new investment. This
definition does not refer to individual health care needs, but uses a population-based
approach. Similarly it does not refer to individual disability support service needs, but to
those that are population-based. The term therefore refers to service needs assessment, not
personal needs assessment.
Health needs assessment is important for governments, health funders, health service
providers and the community, so that the need for health services can be identified,
health service provision prioritised according to the available resources, and services
implemented for the good of the community and the people within that community.
Personal or individual needs assessments are not part of this report.
The literature on health needs assessment is extensive. This paper reports a

considerable body of literature on the subject, most of which comes from the UK. While
there is some literature within New Zealand, most of it is grey literature and
unpublished. A number of New Zealand reports have been accessed, and these are
discussed within the body of this report and/or recorded in Appendix 5. These various
reports will be useful for District Health Boards research on previous assessments in
their districts.
In the preparation of this report Medline, Embase, Ministry of Health and Health
Funding Authority databases have been accessed, along with references within references
and hand searching of journals.
Health needs assessment can be considered to consist of a specific statement and context
of the problem, data collection (including services available), data analysis
(including effectiveness and cost-effectiveness of services), and prioritisation, and is
followed by implementation of health services. Since resources are finite, needs must be
ranked so that resources can be shifted from low- to high-priority needs. New,
potentially effective services must be evaluated for cost-effectiveness, but their
implementation depends on the ability to identify and drop ineffective services.
The various approaches to health needs assessment are discussed, including
global, community-based, epidemiologically-based, comparative and corporate
approaches. It is likely that District Health Boards will mainly use the global approach,
but will also need to consider the benefits of community-based and other approaches.
The epidemiologically-based approach to needs assessment is based on incidence and
prevalence on the one hand, and the effectiveness of health care on the other. It
combines elements of an epidemiological and health economics approach, and
includes prioritisation of health care services for implementation. The comparative
approach contrasts the services received by one population with those elsewhere. The
corporate approach is based on the demands, wishes and alternative perspectives of
interested parties, including professional, political and public views.
The decision on which approach to use will be determined by the objectives of the
health needs assessment under consideration be it global or service-specific.
Available
methodologies are explained in some detail, and referenced for further use.
Numerous approaches to the prioritisation of health services have been used. In New
Zealand these include those of the National Health Committee and the Health
Funding Authority.
These approaches incorporate the use of experts, best-practice
guidelines, principles-based approach coupled with costutility analysis and programme
budgeting and marginal analysis. The approach presently in use by the Health
Funding Authority is described in detail. Citizen juries and community input have
seldom been used in New Zealand to involve the community in prioritisation of
health services, but should be considered.
Consultation with the public regarding health needs assessments will occur through the
process of consultation on the District Health Board strategic plans. The process of
public consultation used by the Health Funding Authority is reviewed for the benefit of
District Health Boards. Consultation is a requirement of the new Act.
xi
The international literature on health needs assessment has been reviewed for examples
of service and treatment areas. These have been presented in table form and indicate
a diverse range of activity.
Case studies demonstrating various types of health needs assessment that may
be conducted by District Health Boards have been presented. None of these fully
represent the global health care needs assessment expected to be conducted by
District Health Boards.
Sources of health information that will be of use to District Health Boards are
briefly summarised in Appendix 3.
Finally, a number of lessons can be learnt from international experience with regard to
health needs assessments. Of particular importance is the need to establish clearly
the objectives for needs assessments and to ensure that robust methodologies are used
and clearly described.
The use of costeffectiveness or cost-utility analysis and a robust prioritisation process are integral
components of the process.
There is little point in
conducting health needs assessment if there is no commitment to implement the
findings, leaving health needs assessment only as a window-dressing exercise.
xii
Chapter 1: Introduction
1.1 Background
The New Zealand Public Health and Disability Act became law in December 2000. The
new Act will provide for the establishment of 21 District Health Boards (DHBs) based
on the current Hospital and Health Services (Minister of Health 2000c). As part of
the reorganised sector, each DHB will be responsible for funding and providing health
care services for the population living in its district.
One set of specific responsibilities of each DHB will be to assess the health and
disability service needs of its local population regularly. These tasks signal an intention to
define and respond to the needs of the local population, including those who do not
access health care services (Minister of Health 2000a).
Health needs assessment is a process whereby funding of health care services can be
prioritised according to the needs of a community for those services within
available resources. The drive towards health care needs assessment is only part of a
package to ensure that the public are explicitly involved in determining the type of, and
priorities for, health care services purchased. Other means include publicly elected
members of DHBs, Board and Committee meetings being open to the public, and public
consultation during the strategic planning processes of the DHBs.
Many countries have been undergoing health care reform over the last decade, including the
UK, USA, Australia and New Zealand. Health care reform in New Zealand has many of
the underlying forces that exist overseas. These reforms have been driven by the need
to control rapid growth in health spending, shifts in the pattern of health service payment
and provision, developments in newer technologies, ageing populations, concerns
regarding the effectiveness of treatments, and a desire to meet the health needs of
populations and individuals better. Health care needs assessment has become an
integral part of health planning and policy, by informing the process of health care
prioritisation and giving the community a voice in the way that services are provided.
New Zealand spends approximately 7.8 percent of its Gross Domestic Product on
health services, a figure similar to that of Australia. There is continuing pressure on
health service spending. A recent analysis showed that New Zealand increased spending
on Hospital and Health Services from $2398 million in 1994/95 to $3548 million in
1999/00, an increase of $1150 million (including GST) or 47 percent (see Table 1). The
ageing population combined with the development of newer technologies, raises the
possibility of ever-increasing health service sector demand.
Table 1:
Trends in health expenditure, 19942001
Year
HFA revenue to HHS (GST

inclusive) ($ million)
2000/01
3763
% total HHS revenue (GST

inclusive) of Vote: Health (GST
exclusive)
61.46
1999/00
3548
60.42
1998/99
2993
54.45
1997/98
2737
53.67
1996/97
2654
56.30
1995/96
2535
57.56
1994/95
2398
58.76
Sources: 2000/01 and 1999/00: Health Funding Authority 2000; all other years: Statistics New Zealand
Note: revenue growth dropped over the earlier years due to residential and aged care services being
transferred from HHS to community providers.
1.2 Structure
Implicit in the task of balancing need for health care and the availability of resources is
the requirement to understand the meaning of need and health care needs, particularly
from the perspective of conducting prospective health care needs assessments.
This
background paper and literature review explores the concept of need, and explains the
relationship between need, demand and supply. It will define need as the capacity
to benefit and health care need as the capacity to benefit in some way from health care.
There are varying definitions of health needs assessment, depending on
interpretations surrounding health, needs, and assessment. Such interpretations are
entirely dependent on how these words are applied to a given situation, who is the
beneficiary of such an assessment and (to a certain extent) how an assessment is
conducted. The next chapter will define health care needs assessment bearing in mind
that cost-effectiveness studies and prioritisation of services for purchasing are an integral
part of that definition.
Health care needs assessment for the purposes of this report is defined as the
assessment of the populations capacity to benefit from health care services
prioritise d according to effectiveness, including cost-effectiveness, and funded
within available resources.
District Health Boards will conduct various types of health needs assessments, and
these types will be described. Cost-effectiveness, cost-utility analysis and programme
budgeting and marginal analysis will be discussed, followed by a section on prioritisation,
including the approach currently used by the Health Funding Authority.
Case-study examples (Porirua-Kapiti) are provided to demonstrate health needs

assessment, disease-specific needs assessment (renal disease), programme budgeting
and marginal analysis, and rapid appraisal. None of these case studies fully represents
the global health needs assessments of the type that will be undertaken by DHBs initially.
The New Zealand context and experience of health needs assessments will be
reviewed, including the link to the Treaty context, particularly with relevance to
DHBs. The UK experience will also be reviewed and generic lessons (dos and donts)
presented.
There are a number of appendices, including sources of health information for
New Zealand, and tables of New Zealand and international references related to health
needs assessments. A full bibliography is supplied.
Chapter 2:
Health Care Needs Assessment
2.1 Introduction
The term health need refers to the broad environment of individual health
and encompasses questions of deprivation and inequality related to the
socioeconomic determinants of health. Meeting health need is an intersectoral
responsibility, and the Governments Closing the Gaps programme intersectorally
addresses the gaps in health, education, housing and welfare.
The term health care need can be used to describe a populations need for the provision
of particular health care services. In an analysis of the resources necessary for the
effective provision of health care, health care needs assessment not only reflects the
prevalence or incidence of the condition or disease state concerned, but the number of
individuals likely to benefit from treatment, who want treatment, and for whom treatment
is generally regarded as a reasonable investment for a publicly funded service. This
clearly involves the process of prioritisation (Frankel 1991).
Health care needs assessment is clearly linked to the concept of need as the capacity
to benefit, but with the proviso that treatment is considered a reasonable investment.
This requirement indicates that there should be some consideration of the effectiveness
and cost-effectiveness of services in which an investment is being considered. Because
available resources in all health care systems are finite, prioritisation will be necessary
for health service purchasing.
Health care needs assessment for the purposes of this report is defined as the
assessment of the populations capacity to benefit from health care services,
prioritised according to effectiveness, including cost-effectiveness, and funded
within available resources.
This definition does not refer to individual health care needs, but uses a populationbased approach. Similarly, it does not refer to individual disability support service needs,
but does include those that are population-based.
The term therefore refers to
service needs assessment, not personal needs assessment. As most of the international
literature referring to health care needs assessment uses the term health needs
assessment. The latter term will be used in this report, and the two meanings will be taken
to be synonymous.
2.2 Context of health needs assessment

Having defined health needs assessment, we now consider needs assessment in
a conceptual framework for the DHB purchasing process. The model shown is adapted
from that originally described by Ferguson and Ryder (1991). The model relates to
the 1991 National Health Service health reforms, which placed the activity of
health needs assessment by district health authorities within an explicitly rational
framework, as one of the essential steps in the process of health care purchasing (Figure
1).
Figure 1:
Conceptual structure for the District Health Board purchasing process

Population characteristics
Classification of disease and disability
Programme budget matrix:

cost and activity data
Assessment of health needs

including: services,
effectiveness, costeffectiveness, needs analysis,
prioritisation
National and local

policy, NZHS, NZDS,
objectives and national
targets
Options for service provision
Community input
Policy statement
Community consultation
for strategic planning
Contract specification
Funding Agreement
Monitoring and review
Cost / prices
Quality of care,
health outcomes,
relativeeffectiveness
Ministry of Health
Source: Adapted from Ferguson and Ryder 1991

Notes: NZHS = New Zealand Health Strategy; NZDS = New Zealand Disability Strategy.
Following collection of data on population characteristics and classification of disease,

health needs assessment (including prioritisation) provides options for service provision.
Policy statements become incorporated into strategic plans (annual plans and 510-year
strategic plans) and are consulted on with the community. Contract specification and
funding through the DHB Funding Agreement will be followed by monitoring of
agreed performance measures by the Ministry of Health. All the above will be set in
the context of the New Zealand Health Strategy (which sets out 13 population health
priority areas) and the New Zealand Disability Strategy. Details of this approach are set
out later.
2.3 Purpose and objectives of health needs

assessments
Determining the purpose and objectives of a needs assessment is an essential step before
choosing the approach to the needs assessment itself. The purpose may be to assess
individual need or that of populations; to allocate scarce resources through prioritising; or
to access the requirement for a more extensive study or simply to highlight problems.
In a review of developing practice in community-based health needs assessment, the
London Health Economics Consortium found that among mainly District Health
Authorities, a common problem was failure to state clear objectives, which resulted in
the choice of inappropriate or unobtainable objectives by default (Hensher and Fulop
1999; London Health Economics Consortium 1996). They identified 15 different
objectives, which can be grouped into four types.
Table 2:
Setting objectives for needs assessment exercises
Type
Objectives
Explicit
Obtain community-based view of health needs

Aid to future accountability
Community input into decisions on health needs
Community input into decisions on health services
Process
Provide evidence to promote health on the agenda of other agencies

Part of an exercise in education on health issues with communities
Public relations exercise to assist in raising profile of DHA, or to inform
decisions made by DHA

Inform wider community-action projects
Other unstated
Provide general political and local legitimacy

Conform to DHA guidance
Co-opt dissenting groups
Hidden agendas
Provision of social commentary

Confirmation of particular ideological position
Demonstrate low level of funding
Make case for more general redistributive policies
Source: London Health Economics Consortium

1996 Note: DHA = District Health Authority.
In the survey of 217 health needs assessments in 14 health authorities in London,

Hensher and Fulop found that needs assessment directly supported decision-making
and action in two-thirds of the studies identified, but that up to 20 percent of needs
assessments had no impact on service provision. In 14 percent of needs assessments, the
objectives were either not stated or not clear. The authors note that care should be taken
to identify those issues
that impose a significant disease burden and from which change might result in
substantial benefit, and to minimise the impact of high-profile or special interest issues to
which detailed analysis will add little value (Hensher and Fulop 1999).
The London Health Economics Consortium (1996) concluded that:
Most of the studies we examined failed to state the reasons for
undertaking the work or why a particular area was selected or how the
exercise fitted in with other planned activities ... It was common for aims
or objectives not to be explicitly stated in the reports ... It is a truism that
the methods are unlikely to be appropriate if the objectives are not clear.
There is a question of legitimacy with regard to unstated aims or objectives (Pfeffer
and Pollock 1993a). The London Health Economics Consortium stated that even if they
were legitimate, it is doubtful whether involving a large number of people, raising
expectations, and committing considerable resources can be justified solely by these
aims. Sometimes the hidden agendas referred to in Table 2 can only be deduced from
some of the language used in the reports or by those undertaking the research. These
rela te to social commentary and taking ideological positions, which has implications for
the funder.
Few would argue with the fundamental aims of health needs assessments to help ensure the
provision and supply of equitably delivered health care. Clear expla nation of the
objectives of such assessments will be necessary to facilitate practical understanding as to
how needs assessments can be undertaken, what support will be necessary and what
benefits can follow.
Part of that understanding is the link between the
assessments themselves, prioritisation, and integration into planning and commissioning
of local health services for them to produce effective change (Jordan and Wright 1997).
These points are underlined by Stevens and Gillam (1998) who, when clarifying
objectives, ask:
Is the needs assessment about populations or individuals?
Is there a clear context for allocating scarce resources?
Is the needs assessment to clarify what should be done, or just to highlight

problems that are accompanied by no obvious intervention? (And is it ethical to do
health needs assessment in this situation if there is no commitment to action?)
Is the determination of the most important needs based on expert knowledge

or participatory methods? (It should mostly involve both.)
Arguably, needs assessment is of little value if it merely confirms the status quo, although
it may confirm that the status quo is actually delivering appropriate services and
meeting needs. Wilkinson and Murray (1998) ask pertinent questions regarding priority
setting in health needs assessments:
Is there a realistic chance of achieving change?
Is the cost of undertaking the work proportional to the likely benefits?
What are the priorities being suggested by other agencies the health authority or
health board, or social services?
Does the [District Health Board] wish to look at issues that are not directly under
their control such as housing and transport (ie, health need)?
District Health Boards could usefully use the following checklist from Wright ed
(1998) when considering health needs assessments:
What is the problem?
What is the size and nature of the problem?
What are the current services?
What do patients want?
What are the most appropriate and effective (clinical and cost) solutions?
What are the resource implications?
What are the outcomes to evaluate change and the criteria to audit success?
The objectives of health needs assessments need to allow for changes in health service
delivery, including withdrawing services in other areas, and to meet newly identified need
rather than perpetuating existing arrangements. Objectives for health needs assessments
need to be clearly stated or there is a danger that needs assessments will become
perfunctory studies, collecting data because it is considered a good idea. Clear objectives
tie the needs assessment into an organisation which then has a sense of direction as to
where the needs assessment is leading.
Wright ed (1998) also underline the necessity for objectives to be clearly defined to
ensure needs assessments are successful. Ultimately, the purpose of health needs
assessments is to inform funding decisions to produce equity and a fair distribution of health
services, health gain, and better outcomes for the population. Educational strategies
should be used to improve the understanding and skills of health professionals and the
public regarding the objectives of needs assessments.
A useful overview is provided by Wright ed (1998):
The planning cycle should begin with the assessment of need (Womersley
and McCauley 1987). Objectives must be clearly defined and relevant
stakeholders or agencies be they primary care teams, hospital staff,
health authorities, the voluntary sector, the media, regional executives,
government, or patients must be involved appropriately. Although such
an assessment may produce such a multitude of needs, criteria can be
used to prioritise these needs for example: the importance of a problem
in terms of frequency or severity, the evidence of effectiveness of
interventions, or the feasibility for change. Needs assessments that do not
include sufficient attention to implementation will become little more than
academic exercises.
In summary, there is a very clear message. The purpose and objectives of health
needs assessment must be clearly defined by DHBs. Acknowledging that needs
assessments will be used to inform purchasing decisions and ensure a fair distribution of
health services, it is timely to consider the five general approaches to needs assessment:
global
community-based
epidemiologically-based
comparative
corporate.
It should be emphasised that in some circumstances several approaches may be

used together, and that in others one approach may be used after another. Each of the
above-listed approaches will now be looked at in turn.
2.4 Global approach to health needs

assessment
2.4.1 Introduction
This is the approach that it is presumed will be taken by DHBs initially to assess
global health care need in their districts. This approach is sometimes called localitybased health needs assessment. DHBs may use shared support facilities to conduct
health needs assessments. The resource of skilled people to conduct assessments is not
large, and for global assessments at least (and maybe others) it makes sense for efforts to
be pooled, and where necessary outside expertise obtained. The Ministry of Health will
be able to assist with data sets and guidance.
2.4.2 Relationship between global health needs

assessment, the New Zealand Health Strategy and
purchasing
It is helpful to refer again to Figure 1 showing the conceptual structures for the DHB
global approach. Global health needs assessments will relate to the New Zealand Health
Strategy, and also the New Zealand Disability Strategy and the New Zealand Mori
Health Strategy, to be published early in 2001. The New Zealand Health Strategy
(NZHS) has established 13 priority population health objectives. The Government
intends focusing Ministry of Health and DHB attention on these objectives. Further
work is being done on issuing guidance to DHBs on each priority area, including
appropriate measures of performance.
With these measures related to the 13 priority objectives in mind, the following
principles apply to DHB global health needs assessments.
Data collected should relate to the NZHS health outcome targets, as a minimum.
The needs analysis stage should include a gap analysis between current DHB
health outcomes and NZHS national health outcome targets.
Prioritisation as an integral part of the health needs assessment process will use
the HFA/Ministry of Health prioritisation framework and will also take account
of the local gaps compared with national health outcome targets.
There is room for local flexibility while maintaining national consistency. This may
be reflected in Funding Agreements.
2.4.3 Characteristics of a global approach

The global approach to health needs assessment consists of tasks and activities shown in
Table 3.
Global health needs assessments differ from epidemiologically-based needs assessments
in that they are service-oriented rather than disease-oriented, despite the use
of epidemiological data. This approach leads to identification of service gaps, and
may identify services that are no longer considered effective, or do not meet current
health care requirements, for a variety of reasons. Where service gaps are identified
(gap analysis), the HFA/Ministry of Health prioritisation approach is then used to
prioritise purchasing of new services.
Table 3:
Relationship between task and activity in health needs assessment

Task
Activity
Setting of objectives
Objective setting
Health care services
Needs analys is
Effectiveness
Cost-effectiveness
Prioritisation
Data collection
Data analysis
Prioritisation
These steps are now explained in more detail.
Setting of objectives
This has already been discussed in 2.3. Objectives should be consistent with the
New Zealand Public Health and Disability Act 2000, Clause 17, Objectives of DHBs.
The function of health needs assessment is mandated by Clause 18, Functions of DHBs
(1f): to
10
regularly investigate, assess, and monitor the health status, of its resident population.
The purpose, question or decision that is being assessed will influence the type and
scope of health needs assessment being conducted.
This section must answer the question Who are the people in need of health
services?. This requires demographic data regarding the population resident in the DHB
area, including an analysis of population trends. The Ministry of Health can provide
data regarding the resident populations of Boards (see Appendix Two). To ensure
standardisation of data across DHBs, the Ministry of Health will supply common data
definitions.
This section must answer the question What conditions do they present with? and
requires epidemiological data. Detailed information is available from a number of
sources (see Appendix Three), but most data will be available from the Ministry of
Health. Hospital discharge and outpatient data is available and in some districts useful
primary care data may be available from Independent Practitioner Associations. It is
anticipated that the current health status of the population will be recorded, along with
risk exposures and associated trends. Mori health data (especially regarding
Mori health gain areas), health determinants, health risk factors, National Waiting
Times Project data, obstetric and perinatal data and dental data will be available.
As a minimum, data will have to be collected in such a way as to inform DHBs
regarding local progress towards achieving national health outcome targets of the New
Zealand Health Strategy.
Two techniques for reporting classification of disease (and service need) are available in
addition to the more traditional methods of reporting in age bands: the life-cycle model
and the geographic al technique. It is anticipated that Boards will report according to age
bands to be determined by the Ministry of Health, but these other methods are
mentioned for completeness.
The life-cycle model considers health needs in the context of the life cycle, with
different age groups considered as different populations (Pickin and Leger 1994). The
model has been used in the Midland Region by the Health and Disability Analysis
Unit, which considered pregnancy and childbirth, infants and children, families, sexual
and reproductive health and the population as a whole. This enabled a very
comprehensive description of the population of the Midland Region and the service needs
of that population. The SF-36 as a measure of health status was also incorporated in the
survey results (Health and Disability Analysis Unit Midland Health 1994, 1995, 1996,
1997a, 1997b, 1998a, 1998b).
Geographical techniques are becoming attractive. These attach health data to
geographical areas, with approximately 90 families per meshblock. In the most advanced
form, primary health care data such as Read Code diagnoses and acute care data such
as Diagnostic Related Groups (DRG) utilisation ICD-10 coded discharges can be
directly tied to
Any factors that the DHB believe may adversely affect the health status of the population, and the need of
that population for service.
11
meshblocks. This allows an assessment of services according to geographical location.

An example of such an assessment would be a geographical needs assessment that
located a high percentage of asthmatics around an industrial plant, or diabetics in a low
socioeconomic area. Meshblock geo-coding allows association of deprivation index
scores such as the NZDep96 (Crampton et al 1997; Salmond et al 1998) with disease
coding or other data. Health services can be planned to meet identified need. This
assumes that prevalence of disease equates to need, which is not necessarily so. The
geographical technique is also useful for the epidemiologically-based health needs
assessment approach.
Health care and disability services
These can be analysed on three levels:

a)
Health care service providers. This could include such providers as Hospital
and Health Services, public health services, private hospitals, primary care services,
Mori health services, Pacific health services, maternity services, child and youth
services, mental health services, disability support services, and community and
voluntary services. In many cases the DHBs will be able to identify service
providers through the DHB contract database.
b)
Health care and disability support service utilisation. Utilisation data is

available for a range of private and public services. Primary care referral and
utilisation data is available from Independent Practitioner Associations and Health
Benefits Limited.
c)
Community and provider views on service and disability support provision. A

number of methodologies are available to obtain views from these groups,
including community surveys, community group interviews, consumer focus group
interviews, key informant interviews, health service provider surveys, and
interviews and rapid appraisal. These methodologies are discussed in more detail in
the following sections on community-based approaches for health needs assessment.
Needs analysis
This is one of the more critical components of health needs assessment. Once data
has been collected from multiple sources, analysis is required. As discussed above, there
should be a relationship between the global health needs assessment, NZHS
national health outcome targets and purchasing.
The process includes the following:
a)
obtain the national health outcome targets
b)
analyse existing data for current performance against the indicators
c)
identify gaps against national indicators (gap analysis)
d)
identify other service gaps that have become apparent in the data collection process
e)
acknowledge local community views on health service provision priority areas

(this should also take account of the silent voices in the community)
f)
tabulate present service gaps and consider any unnecessary services
12
g)
proceed to effectiveness, cost-effectiveness and prioritisation.
6
7
8
Effectiveness
Cost-effectiveness
The prioritisation stage of health needs assessment
These three steps are interlinked and apply to many health needs assessments. They are
discussed together in Chapter 3.
2.5 Community-based approaches to health

needs assessment
Fundamental to the approach to health needs assessments in communities is recognition
of the principles of the World Health Organization. This requires a multidisciplinary
approach to health need, influenced by the determinants of good health (World Health
Organization 1985, 1992).
A community-based needs assessment refers specifically to the process of identifying
the needs of the local population through consultations with the public. A community-led
health needs assessment, in contrast, refers to health needs assessment that is led by a
community empowered to provide such leadership. This model has not been adopted
widely, mainly because it is time consuming and appears to be more suitable to the
community development models of care delivery and community action. It may also lead
to loss of control by health authorities.
There is debate over whether needs assessment exercises should be community-based
or community-led (Wainwright 1994). However, a small number of health authorities
in the UK report the use of the community-led needs assessment approach, but
involving community members as equal partners in the research process (Ealing Health
Agency 1995; Bromley Health 1995).
According to Ong et al (1991), most community-based needs assessments incorporate
a high level of user and community involvement and:
are concerned with either health services or general social and environmental issues
that affect health
examine small areas or small population groupings
involve work in the field
adopt a flexible approach
base the assessment largely on qualitative data derived from the perspectives of
the local community.
One example of community-based needs assessments is community profiling, which

can be used by professionals involved in the planning and delivery of services,
community workers, community organisations and voluntary groups (Hawtin et al
1994). The main
13
difference between epidemiologically-based approaches and community-based

approaches is that the former generally focus on a disease, while the latter are based in
the community and are service rather than disease focused, but will utilise the methods of
epidemiology.
Within the community-based approaches to health needs assessment a number
of approaches are used: primary care, community-oriented primary care,
community development, rapid appraisal and rapid assessment approaches. Each of
these has their own characteristics, which are described below.
2.5.1 Primary care approaches

Most information on the primary care approach to health needs assessment originates
from the UK, where health reforms in 1991 provided for health needs assessment.
Some time later, the Secretary of State for Health (1997) required that Primary Care
Groups, consisting of a wide range of primary care health professionals, conduct needs
assessment based on the populations of their groups (approximately 100,000),
taking a community-based approach. Numerous authors have described ways of
assessing health needs in primary care (Wilkinson and Murray 1998; Gillam and Murray
1996; Wright et al 1998a; Hooper and Longworth 1997; Harris 1997; Murray and
Graham 1995; Scottish Needs Assessment Programme 1998; Murray 1999; Murray et
al 1994; Shanks et al 1995). Many of these publications refer to health needs
assessment at the practice level. Others refer to larger populations: Generally, larger
populations will produce more robust results than single practices. There is also no
need for every practice to carry out similar studies when it is unlikely that there will be
different needs between practices (Wilkinson and Murray 1998). Starfield (1996)
discusses the way that public health and primary care can work together, including
health care assessment and measurement of effectiveness of services for the
consumer, largely in managed care environments.
Wilkinson and Murray (1998) have proposed a five-stage approach to performing a
health needs assessment at practice or primary health care group level. It is not
anticipated that DHBs will use this approach initially, but the approach is useful and may
have relevance for the future.
Stage 1: Collect routine practice information

Routine data is collected from practices according to the data referred to in Box 1.
This figure lists practice data available in a reasonable number of UK practices and
gives an overview of practice needs. Much of this data is available through practice
databases. Several networks are available to assist practitioners with the collection and
analysis of such data (Smith et al 1995).
Box 1:
Core practice data
Age-sex profile in 5-year bands for male and female patients
Prescribing details:
repeat prescribing rates from practice computer
14
Prevalence of some specific chronic disease (eg, ischaemic heart disease,

chronic obstructive airways disease, asthma, epilepsy, psychosis, thyroid
disease, hypertension, diabetes)
Data from practices payment details:
percentage of patients attracting deprivation payments
family planning uptake
temporary residents
obstetric care and other item of service payments
Health promotion and disease prevention data:
smoking, alcohol consumption, substance misuse, body mass index
immunisation coverage (2- and 5-year-olds)
cervical cytology coverage
Contacts with general practitioners:
surgery consultation rate per 1000 registered patients per year
house call rate per 1000
out of hours visits per 1000
Knowledge (mostly implicit) of local health needs:
health visitor: practice profile, breast-feeding rates, use of other agencies
district nurse: workload details, observations in patients homes
practice nurse: workload details (eg, influenza coverage rate)
receptionists: patients perceptions, availability of appointments
Deaths: causes, place of death, preventable factors
Turnover of patients
Other sources: suggestion box, patient participation group
Notes search may yield:
incidence of acute illnesses and symptoms presenting
telephone ownership (percentage)
unemployment rate, domestic problems documented.
If reliable data (on use of investigations, referrals, etc) are available from other
sources, use these data rather than duplicate work in the practice for the
following:
use of investigations (per 1000 patients per year), individually for

microbiology, haematology, biochemistry, radiology, electrocardiography
referrals to physiotherapy, chiropody, occupational therapy (per 1000

patients per year).
Source: Wilkinson and Murray 1998
Stage 2: Collect data from hospitals, community health services

providers and the census
Use of hospital services may not be a proxy for morbidity in the community (Payne et
al 1994). With the help of local hospital public health departments, detailed hospital
utilisation can now be compared between practices and localities. Hospital discharge data
may not be
15
a proxy for need, but for demand and supply. Box 2 lists the variables that general
practitioners working in Edinburghs south-east locality found most informative
for understanding the current usage of hospital services by individual practices
(Wilkinson and Murray 1998).
Box 2:
Data from hospitals, community health service providers and the census
Inpatient data
Ten most frequent diagnoses made at hospital inpatient discharge (rates per 1000
registered patients), tabulated in descending order (ICD-10 codes to 3 digits are
recommended; transfers are excluded; patients with multiple discharges from the
same hospital, using the same facility and with the same diagnosis are counted
only once)
Elective admission (rate per 1000 residents)
Non-elective admission (rate per 1000 residents)
Mean waiting time (days)
Ten most frequent day-case diagnoses (per 1000 patients), in descending order of
frequency
Top three day-case procedures (per 1000 patients), in descending order of

frequency
Outpatient data
Outpatient referral rate per 1000 residents
Referral rates for 5 most used specialties, tabulated in descending frequency
Mean waiting time (days)
Attendances at accident and emergency department (per 1000 patients per year)
Obstetric data
Births (rate per 1000 residents)
Community data
District nursing visits (per 1000 residents per year)
Health visitors visits, and clinic attendances (per 1000 residents per year)
Investigations
Use of investigations (per 1000 patients per year) for microbiology, haematology,
biochemistry, radiology, electrocardiography
Referrals
Physiotherapy (per 1000 patients per year, clinic and domiciliary)
Chiropody (per 1000 patients per year, clinic and domiciliary)
Occupational therapy (per 1000 patients per year)
Census
Percentage of residents with limiting long-term illness
Demographic profile, in 5-year bands
Unemployment rates (%) for men and women
Percentage of house owners
Percentage of car owners
16
Percentage of households with lone parents
Stage 3: Gaining public involvement

Health professionals typically define needs in terms of services they can provide,
whereas patients may have a different perception of what would make them healthier: a
job, a bus route to the hospital, or some advice on benefits. In light of this, an
honest consumer perspective can be gained through:
interviews with patients
informal discussions with, for example, voluntary groups, community health council
suggestion boxes
complaints procedures
health forums
focus groups (with older or diabetic patients, for example)
rapid appraisal
use of key informant networks (Gregor and Galazka 1990).
Box 3 gives information on how to run focus groups.

Box 3:
Focus groups
Focus groups
Facilitated discussion groups that allow the members of the target population to
express ideas spontaneously.
Can give useful insights into perceived needs, quality of services, and
understandings of health issue.
Can raise issues that are important to patients.
Information gained is not quantifiable.
Facilitators need some training.
A variety of groups may be necessary to be representative in some situations.
Practical points
Optimal size is 812 participants.
Facilitator introduces topics for discussion.
Proceedings are recorded using a tape recorder and later transcribed, or notes are
taken, preferably by another facilitator.
17
Stage 4: Undertake survey

Community surveys can be used to obtain data from the community on the true burden
of morbidity, the perceived need for services, satisfaction, and so on.
Various
validated instruments for generic and disease-specific surveys are available (Wilkin et al
1992). Their use necessitates assistance with the selection of survey tools, sampling and
analysis of data. Box 4 suggests areas for questionnaire surveys.
Box 4:
Areas for questionnaire surveys
Acute illnesses and experience of common symptoms
Use of health services over the past 6 or 12 months
Patients satisfaction
Perceived need for current and potential services
Specific concerns and worries that may affect health
Specific questions for people with specific long-term health problems of carers
Chronic illness (may not be necessary if data obtained already):
Any long term illness
Several marker conditions (eg, hypertension, back pain)
Consider a general health status instrument (SF-36, SF-12)
Consider a disease-specific questionnaire
(Consider checking a sample of medical records from non-respondents.)

Stage 5: Collation of the information from the different sources

A triangulation approach is useful in assessing health needs where different information
sources and methods of gaining information give complementary insights into health
needs generally (Murray and Graham 1995). The findings then need to be analysed and
presented to the practice team or the primary care group. As a result of the health
needs analysis, new initiatives will be identified, prioritised, and then incorporated into
the business plan for the new year. Resources will need to be identified to allow
implementation of the planned initiatives.
2.5.2 Community-orientated primary care approaches

(COPC)
According to Abramson (1988), the essential features of COPC are:
There must be a defined community or aggregation of people for whose care the
service has assumed responsibility.
18
Primary clinical care must be provided for individuals in this community.

This personal care may be provided by doctors, nurses or other health workers; in
different situations it may be curative, preventive or comprehensive.
There must be defined programmes to deal in a systematic way with the

communitys major health problems. These community health programmes ... may
involve health promotion, primary or secondary prevention, curative, alleviative or
rehabilitative care, or any combination of these activities.
COPC is an approach that uses epidemiological and clinical skills together to provide
programmes for meeting the needs of a population. COPC has been described by numerous
authors (Kark and Abramson 1981; Kark and Kark 1983; Nutting et al 1985; Nutting
and Connor 1986; Abramson 1988; Wright 1993; Garr et al 1993; Cashman et al 1994;
Nevin and Gohel 1996; Freeman et al 1997; Tollman 1991; Coster and Gribben 1999;
Crampton 1999). The Codman Square Community Partnership for Health Promotion used
the COPC model to promote changes in individual and community relationships to reduce
the morbidity and mortality associated with the many problems facing the poor, minority
communities in the United States.
Needs assessment and ongoing data collection
formed one of the objectives of the project (Schlaff 1991).
Kark (1981) has listed the following cardinal questions that practitioners of COPC need
to answer. At least three require epidemiological skills:
What is the state of health of the community?
What are the factors responsible for this state of health?
What is being done about it by the health service system and by the community itself?
What more can be done, what is proposed, and what is the expected outcome?
What measures are needed to continue health surveillance of the community and
to evaluate the effects of what is being done?
The actual steps of COPC have been described in the following manner:
First, a primary-care or public-health program defines and characterises
the community for which it has assumed responsibility. Second, the
program organises and involves the community so that the groundwork
for a communityprofessional partnership is laid. Third, a community
diagnosis/needs assessment and a resources inventory are conducted.
Fourth, community-based interventions are developed and implemented.
And, fifth, ongoing monitoring and evaluation procedures are put in
place (Cashman et al 1994).
These features together constitute a cyclical process beginning with the
systematic collection of information, which is then used to implement services followed
by evaluation, leading to a continuous feedback of epidemiological and other information.
The main stages of the process are shown in Figure 2.
19
Figure 2:
The COPC cycle
Source: Abramson 1987
For DHBs, it would be relevant to discuss with Health Care Aotearoa organisations,
which have a community-based focus (Crampton 1999), any health care needs
assessments they have conducted for the communities within their own organisations.
Within each community there is likely to be a degree of homogeneity, which would
facilitate needs assessment processes within these sub-populations.
2.5.3 Community development approach

The community development model is described as a process by which people are
involved in collectively defining and taking action on the issues that affect their lives.
The process is collective, but the experience is individual.
Community
development seeks to enable individuals and communities to grow and change
according to their own priorities (Labrynth Training, cited in Freeman et al 1997;
Fisher et al 1999).
Meanings of community have been
explored from the perspective of community participation in health promotion (Jewkes
and Murcott 1996). The community development model recognises the social, economic
and environmental models of ill health and links user involvement and (purchasing) to
improve health and reduce inequalities (Fisher et al 1999). Community needs
assessment is conducted in the community development model. Although the model is
regarded as important, it is not common in New Zealand.
2.5.4 Rapid appraisal approaches

The technique of rapid appraisal is commonly used to conduct needs assessments
in communities. It has evolved to assess community need in urban settings, rural
communities, or following disasters and emergencies (Chambers 1981; Wood 1981).
Annett and Rifkin (1988) have adapted the framework for health use in low-income
urban areas in developing countries. Murray et al (1994) have used the methodology for
listening to local voices in health and social planning, while Gillam (1992) discusses its use
in obtaining structured views of local communities in general practice situations. It has
been used to identify the need for reproductive health care in southern Sudan, using
interviews with key informants, in-depth interviews, group discussions, and use of
secondary data to involve communities in assessing needs and planning service
provision (Palmer 1999). This study
20
concluded that community leaders and health service providers will not necessarily hold
the same view of need as community members, and that rapid appraisal may be a useful
tool to identify communities needs and priorities. The techniques of rapid appraisal are
different and involve community consultation as an integral component of the
methodology. The objectives are to provide good-quality, timely information, and to
include local people, producing results that would lead directly to interventions.
Various methods can be used to collect information using rapid appraisal, including
interviews with key informants; in-depth interviews; group discussions or focus groups
(Kitzinger 1995, 1997); matrix ranking, freelisting and scenarios; and secondary-care
data. Semi-structured questionnaires are used as a guide for key informant and
in-depth interviews (Annett and Rifkin 1995), as well as topic guides for group
discussions, all of which should be piloted before using for data collection.
Freelisting involves
asking participants to list illnesses, needs, health care resources or community priorities
(Weller and Romney 1988). The main advantage of this technique is that it tells us the
degree of general awareness of a problem (Pelto 1998). In matrix ranking, problems or
illnesses are ranked according to several different criteria (Welbourn 1992). This gives
information on how a community prioritises one problem above another.
Box 5:
The technique of rapid appraisal
Rapid appraisal methods seek to gain community perspectives of local health and
social needs and translate these findings into action. Such methods have been
designed to draw inferences, conclusions, hypotheses, or assessments in a limited
period of time and are thus relevant to health service research and health needs
assessment.
Data is generally collected from three main sources:
interviews with a range of local informants
existing written records about the neighbourhood
observations made in the neighbourhood or in the homes of the interviewees.
From the information thus collected an information pyramid can be assembled

describing the neighbourhoods problems and priorities (see Figure 3). The pyramid
shape is a reminder that this methods success depends on building a planning process
that rests on a strong community information base. The scientific rigour and the validity
of the approach depend on triangulation. Data collected from one source is validated
or rejected by checking with data from at least two other sources or methods of
collection. Informants are not selected randomly but purposefully that is, asking a
range of people who are in the best position to understand the issues. Including
relevant interviewees and summary health data from primary and secondary care can
incorporate professional insights. The World Health Organization has published useful
training materials.
Source: Annett and Rifkin 1995
21
Figure 3:
Information pyramid constructed for rapid participatory appraisal
Health
Policy
Educational
Services
Physical
Environment
Community
Composition
Health
Services
Socioeconomic
Environment
Community Organisation
and Structure
Social
Services
Disease and
Disability
Community
Capacity
Source: Annett and Rifkin 1988
Murray (1999) reports on five applications of public participation in assessing needs,

using populations ranging from 1200 persons up to 120,000. He notes that in common
with other approaches, rapid appraisal methods have limitations and values. There are
limitations of bias (informants and researcher), data used (resource constraint and
limited time frame), training necessary for interviewing and understanding the
technique, project co-ordination, and working with diffuse practice populations instead
of communities. With respect to values, he observed that rapid appraisal is community
oriented (the public was of necessity involved) and multisectoral. It also promotes
equality, flexibility and multi-method use and user satisfaction.
It was found that a postal survey could usefully give extra data about acute and
chronic illness in the community and perceived needs for existing and potential services
for both users and non-users. Practice data available from computerisation can best detail
morbidity in primary care, prescribing and health promotion activities. In New
Zealand it is also possible to obtain this data from some Independent Practitioner
Associations (IPAs) and practices, and by geocoding to obtain the distribution of
disease index (linked to Read coding) by address. Additional
information
is
available according to the degree of sophistication of data collection systems within
IPAs.
One study assessing community perceptions of health needs in south-east Edinburgh
was reported as a failure, owing to the non-homogeneous nature of the group under
study (Murray 1999). Rapid appraisal works best in small homogeneous communities
and the method could not be carried out without subdividing the area into natural
communities where key informants know about local problems. There were insufficient
resources to enable this to be done.
22
The key lesson for DHBs is that assessment of community needs using the methods of
rapid appraisal can only occur successfully if the community is formed into small
subdivisions of more or less homogeneous groupings. These methods can then focus
on the needs of specific groups within the community. Additionally, information from
rapid appraisal can be supplemented by data collected from local statistics, postal
surveys and general practice (Murray and Graham 1995).
The opponents of rapid appraisal consider that it has more to do with raising
political awareness and is incapable of delivering objective data about the health
state of a community (Pfeffer and Pollock 1993a). Although it has been claimed that
the techniques of rapid appraisal can produce results within two weeks, more commonly
health authorities have found that it takes up to six months to complete the exercise.
2.5.5 Rapid assessment approaches

In emergencies, needs are most often assessed using rapid assessment procedures, which
do not often include contributions from the community (Glass et al 1980; Shears et al
1985; Guha-Sapir 1991).
Rapid health needs assessment has been used following Hurricane Andrew in Florida
and Louisiana in 1992 (Hlady et al 1992). Using grids of the populated areas, 30
groups of homes were randomly selected and people from seven households in each
group were interviewed using a standardised questionnaire that included a wide range
of questions regarding potential immediate need. The results of these questionnaires were
transmitted to authorities within four hours and were used to set priorities for response.
The Centres for Disease Control (CDC) editors note concluded that Rapid
epidemiological assessment is essential to assure that decisions on the allocation of
resources are based on the best available information (p.1841).
Rapid
epidemiological assessment of the affected population has been recommended as
the most important initial step in guiding the emergency response (Glass and Noji
1992).
2.5.6 Other methods for community-based needs

assessment
A report for the London Primary Health Care Forum noted that an increasing number
of health authorities combined a number of approaches, including rapid appraisal, COPC
(Kark and Kark 1983; Wright 1993) and quantitative techniques. These methods
may share similar characteristics but may differ in modes of application. The authors
found that in addition to setting clear objectives, other determining factors of an
effective needs assessment exercise are the emphasis placed on the different approaches
that are applied, their order of application, and the weights given to the results. The most
common methods are shown in Table 3.
23
Table 3:
Methods that supplement community health needs assessment
General category
Characteristics of approach
Epidemiological assessment
Epidemiological approach designed to produce in-depth
profile of needs.
Focus is on disease and incorporates demand and need
measures.
May be rapid and high level or more commonly at level of
detail incorporating small-area analysis.

Life-cycle framework
Epidemiological approach with population segmented
primarily by age rather than disease group (Pickin and

Leger 1990, 1994).
Intended to be small-area analysis.
Life style / satisfaction surveys
Large descriptive household surveys (Camden and
Islington Health Authority 1992; Ministry of Health 1999d).

Broad information on health status.
Information comes in form of rating scales, service use
and satisfaction, opinions regarding general environment.

Community-orientated primary
care (COPC)
Epidemiological approaches.
Mixed scanning approaches.
Comparative approaches.
Corporate approaches.
Intended to be small-area analysis, although may lend
itself to larger areas (Kark and Abramson 1981; Kark and

Kark 1983; Wright 1993).
Service reviews
Incremental approaches.
Supply-led approaches.
Uses epidemiological approaches.
Uses comparative service and demand data.
Involvement of users, potential users, carers and
relatives.
Not specifically a small-area approach.
Source: London Health Economics Consortium 1996
Note: New Zealand reference added.
Approaches to community needs assessment are reviewed by Bowling (1992), who argues
as a result of a literature review for a multi-focal approach involving qualitative
and quantitative data.
Nichter (1984) regards local participatory research groups as a sensitive means of
obtaining data on communities. In terms of community diagnosis objectives, he agrees
with three participatory research objectives noted by Tandor (1981):
24
to challe nge the expert knowledge being used by planners and decisionmakers, revealing both the incompleteness of assumptions and inadequacy of knowledge
to foster an alliance between professional researchers and lay representatives,

according them the opportunity to contribute to the process and direction of enquiry
to translate popular knowledge into a form that planners and decisionmakers understand, and expert knowledge into a form the lay population can
understand, making for better dialogue.
From his work on Project Community Diagnosis on a large health project in South
India, Nichter found that participatory research gave good information on community
involvement in primary health care and the use of government health facilities. In addition,
he suggested that data produced by local participatory research groups will prove to be far
more sensitive than that produced by periodic social surveys conducted by researchers
from outside the region (p.248). Such methodology is used for research among Mori to
understand Mori health (and other) needs.
2.6 Epidemiologically-based approach to

needs assessment
Epidemiologically-based approaches involve a clear statement of the population
group whose needs are to be assessed (normally a group with a particular disease).
Epidemiology has been defined as the study of the distribution and determinants of healthrelated states or events in specific populations and the application of this study to control
of health problems (Last 1995).
Williams and Wright (1998) observe that it tends for the most part to use the
medical model of health need, viewing need in terms of the occurrence of specific
diseases and health-related states rather than in terms of felt need. Descriptive
epidemiology (as opposed to analytical epidemiology the investigation of the
determinants of health-related states or events) describes the occurrence of disease in terms
of person, place, and time:
person who the affected people are (in terms of their age, sex,
occupation, socioeconomic group etc)
place where they are when they get diseases and in what way prevalence and
incidence vary geographically (locally, regionally, nationally, or internationally)
time when people get diseases, whether this varies by (for example) season;
and how disease occurrence is changing over time.
The epidemiologically-based approach has been well described by Stevens and Raftery
(1997). This is summarised below, with the addition of prioritisation since this is regarded
as an integral component of health needs assessment for DHBs. The approach
makes a number of assumptions.
Needs
are best described in terms of disease rather than population groups

or services. The logic is that a need arises when there is a reason, rather than when a
25
person has reached a certain age, belongs to a racial sub-group, or because a

particular service is provided.
Non-local data is valuable for local needs assessment. While significant

differences exist in the need for health care services in different localities, often
the only source of epidemiology and effectiveness studies is research carried
out elsewhere. Prevalence studies undertaken in one locality may apply
elsewhere, although local studies, if available, are better. However, costeffectiveness studies require local calibration, because unit costs are known to vary
widely. Generic valuation of health status and estimates of cost-utility estimates,
such as costs per quality-adjusted life year (QALY) gained, may also be specific to
the circumstance where the data was gained, and require careful interpretation.
Both costs and cost-effectiveness have to be taken into account in needs

assessment. Although need is a function of benefit, not of cost, the purpose of
population needs assessment is to help decide between competing priorities; the
priorities given to a particular need will depend on both benefits and costs.
2.6.1 Components of epidemiologically-based

approaches to needs assessments
The main components of the epidemiologically-based approaches to need
assessment (adapted from Stevens and Raftery 1997) are:
1
statement and context of the problem
sub-categories
prevalence and incidence
services available
effectiveness and cost-effectiveness of services
models of care
prioritisation
outcomes and targets.
These steps are described below.
Statement and context of the problem
Needs assessment exercises require a clear statement of the problem, the scope, and
the context in which it has arisen. This has been discussed earlier. In many instances a
disease does not occur in a single well-defined service setting, but across service
boundaries (for example, diabetes, which is managed in both primary and secondary care
settings).
26
Sub-categories
The health problem should be subdivided into categories as a critical step in

needs assessment to identify the scale of the problem and the range of needs and services
required (for example, the distinction between asymptomatic HIV and full-blown AIDS).
Prevalence and incidence
These form the basis of epidemiologically-based health needs assessment. However,

prevalence and incidence are not always synonymous with need (ie, disease does not
equal need), and implications for service vary by disease.
A need
for something implies effective treatment. The prevalence of obesity says little about
the need for treatment services. However, prevalence or incidence can quantify unmet
need where an existing service of known effectiveness does not match the known
case load. End-stage renal failure is an example of incidence quantifying need. Where
an unmet need is matched with a service of unproven effectiveness, pursuit of need
assessment is of a much lower priority.
Services available
Although the current type and level of health services are not necessarily aligned to need,
a stocktake of such services is required for comparative analysis. The quantum of
the components of the existing service should be carefully measured, and should be done on
the same basis as is used in cost-effectiveness studies. Structures, processes and outcomes
are also useful measures for describing health services.
Effectiveness and cost-effectiveness of health services
Knowledge of efficacy, effectiveness and cost-effectiveness of services is necessary for

achieving population benefit through restructuring of health services. Efficacy refers to
the benefit achieved when an intervention under study is operating in ideal conditions,
whereas effectiveness refers to an intervention when actually employed. Knowledge of
efficacy offers greater scope for restructuring services, and knowing the
effectiveness on a population basis takes the potential analysis further. Where the
effectiveness is not known, this should be clearly stated.
In
an
analysis
of
service efficacy, the strength of recommendation can be categorised according to the
strength of evidence to support the use of a procedure. Epidemiological data is taken as
the starting point before looking at effectiveness data and then cost-effectiveness data to
identify what percentage of prevalent cases are able to be treated at reasonable cost.
Models of care
Various models of care based on need are developed. The approach scores the service
level appropriate for different interventions (for example, prevention, treatment,
rehabilitation in different sub-categories of a disease group, for example, population at
large, people with mild disease and people with severe disease).
According to Stevens and Raftery (1997):
27
Two potential models of care loosely based on coronary heart disease are
shown in Table 5. One model is prevention-oriented and the other
treatment-oriented; both assume similar total resource levels. Such
models expose the options to a purchaser and set possible directions for
change. Ideally, given the unknowns in the system, several models would
be elaborated for each disease.
Table 5:
Two hypothetical models of care (eg, for coronary heart disease), showing level
of interest for purchasers
Sub-category
Prevention
Intervention treatment
Rehabilitation
Low
Nil
Nil
Medium
High
Low
Low
High
Low
High
Nil
Nil
Medium
Medium
Low
Low
Medium
High
Model I:
A treatment-oriented service
Population at large
Mild disease
Severe disease
Model II:
A prevention-oriented service
Population at large
Mild disease
Severe disease
Source: Stevens and Raftery 1997
Stevens and Raftery continue:

Such models would be of greater use if they were accompanied by a level
of detail that defined what the preventive programmes should be, and
even more, made explicit what the reductions in the current overemphasised areas of treatment should be.
The epidemiologically-based reviews found that models of care came in four main
groups. The table below presents these, along with the topics covered in those reviews.
Table 6:
Groupings of models of care
Model of care
Topic
Meeting need
Elective surgery (hip, knee, cataract, hernia, varicose veins,

prostatectomy), renal, diabetes mellitus, people with learning
disabilities, family planning
Shift to prevention
Lower respiratory disease, lung cancer, coronary heart disease
28
Improved co-ordination
Adult mental illness, dementia, alcohol misuse, drug abuse
Other
Stroke, colorectal cancer, community child health services
Prioritisation
The epidemiologically-based approach to health needs assessment only prioritises within

a particular disease category, not between diseases. It uses effectiveness and costeffectiveness as the basis for prioritisation.
Outcomes and targets
According to Stevens and Raftery (1997):

The identification of outcome measures, which might be used in practice
to monitor services, is part of the process of developing tools for bringing
about change.
Outcome measurement may be more immediately
acceptable and useful if limited to particular diseases, eg, the avoidance
of relapse in schizophrenia, improved lung function measurements in
respiratory diseases and improved activities of daily living for people with
disabilities.
The Ministry of Health regularly sets national health outcome targets, many of which
are relevant to epidemiologically-based reviews.
2.6.2 Conclusion
Epidemiologically-based health needs assessments offer a model of health need
assessment based on best available information regarding current health services,
prevalence and incidence, and effectiveness and costs to derive optimum models of care
based on need. They will be particularly useful for attention to regional and tertiary
services, and in some cases DHBs will choose to use the approach to health needs
assessments for certain services within their districts. A case study of the use of an
epidemiologically-based health needs assessment, using renal disease as the example, will
be described in a later chapter on case studies.
2.7 Comparative approach to needs

assessment
The comparative approach to needs assessment contrasts the services received by the
population in one area with those elsewhere. This is particularly useful where there is
no definition of an optimum service, and it allows comparison of service provision
between areas. The approach can be used at several levels. Firstly, it is useful when it
is applying population-based funding formulas to the DHBs operating in a capitated
environment.
29
Providing the formula recognises the various factors affecting need, common to
such formulas, then this should allow a fair distribution of resources. Secondly,
comparison between districts of health service delivery against need can point to
differences in the way funding is spent, or can be redistributed, or can highlight the need
for additional resources because of recognition of unmet need. Variation in price and
volumes (service use) may be appropriate depending on local circumstances, but with
capitation funding of health care, gross departures from the mean require justification.
The National Waiting Times Project, and the associated clinical guidelines for access to
surgery, is one example of a national benchmark for access to health services. A
comparative approach can be taken to judge service access across districts. Similarly,
public health performance targets (for example, immunisation) allow comparison between
districts. Comparative service provision should take account of local
population characteristics such as demographics and morbidity/mortality data. Careful
interpretation of data is necessary within the comparative process.
2.8 Corporate approach to needs assessment

The corporate approach to needs assessment is based on the demands, wishes and
alternative perspectives of interested parties, including political and public views (see
Figure 4).
Figure 4:
Contributions to the corporate view of local service needs
Purchaser
Providers
Opinion
leaders
Professionals
Corporate
View
Patients
Politicians
GPs
30
Press
Corporate approaches involve the collection of health data on health services from
key informants, including staff of health authorities, provider clinicians, general
practitioners and consumers of health services. Clearly there is potential for provider
capture, but failure to consult with clinicians will result in the loss of a potential
source of information. Consultation with consumers is important if local knowledge and
sensitivity to consumer need is to be obtained. Stevens and Gillam (1998) observes that
where cost-effectiveness considerations are otherwise of equal weight between
services, local concerns may justifiably attack priorities to particular services. In
addition, while a corporate approach blurs the difference between need and demand, and
between science and vested interest, it also allows scope for managing supply and demand
at the same time as assessing need that is affected by local circumstances Stevens and
Raftery (1997).
In some respects the New Zealand Health Strategy takes such an approach (Minister of
Health 2000d). It involves agreement among experts (Expert Advisory Group), use of
key informants (Sector Reference Group), and involvement of the Ministry of Health and
Health Funding Authority.
Following this process, the policy document has
proceeded to consultation with general practitioners, clinicians and consumers of
health services. It provides a corporate approach to the assessment of health need, and
is presented as health policy that will be updated on a regular basis.
With the corporate approach, the key party interested in change must be the patient.
This assumes that the views of patients can be considered part of need assessment since
patient satisfaction is a crucial area of benefit. Elucidating the views of the local
population is a complex task and requires a considered approach. Many health
authorities in the UK are experimenting (both formally and informally) with methods of
assessing local views on demand (Bowling et al 1993; Pfeffer and Pollock 1993b).
2.9 Assessing the methods

Differing methods are used with each approach to gain information to inform
the assessment. DHBs should ensure that methods used are appropriate and clearly
described. Many health need assessment reports reviewed by the author were
unclear on their methods.
Meaningful assessment of needs is the key to successful purchasing (Gillam 1992).
By implication, if the assessment is not meaningful, or accurate, or uses inappropriate
methods, then successful purchasing is unlikely to follow. In a study to assess the
feasibility of using patients perceptions of need for primary health care services to
develop priorities, Hopton and Dlugolecka (1995b) found that Methodological efforts to
ensure equal participation in the processes of assessing health needs and of priority
setting do not in themselves promote equity. They concluded that to promote equity,
some opinions need to be given greater weight.
This means that in health needs assessments, the opinions of minority groups will have to
be given greater weight than would otherwise be the case, in order to promote equity.
This particularly refers to the voices of least-heard ethnic minorities (eg, non-Mori
ethnic
31
minorities like Korean, Chinese, Indian and Pacific peoples). Assessors will have to
work hard to gain the views of minorities and add weight to their views and needs.
In addition the following points must be noted.
Caution should be exercised when using only a single source for assessment.
Data may understate the prevalence of disease in a community (similarly the

number of inpatient admissions is not a proxy for morbidity in a community in
most instances (Payne et al 1994).
Postal surveys should be interpreted carefully, especially when patients and

health professionals may have different understandings of language.
In-depth interviews should be sufficient in number to achieve meaningful

and sustainable results.
Results are more likely to be relevant if data is checked against data from other
sources (triangulation) to draw a conclusion regarding need.
Different methodologies may be required for the assessment of need to inform

the process (Murray and Graham 1995).
Patient surveys overcome important limitations of assessments of need based on the views
of health professionals or routine data. In some situations adopting a comparative
survey approach is found to be a useful method of developing an understanding of patterns
of need and demand among general practice populations (Hopton and Dlugolecka
1995a). However, even this method has limitations and the method chosen depends
on what information is sought.
In some cases it may be appropriate to include an in-depth analysis of the needs of
particular groups. Where this has been done in the past, it has been found to be useful
for service development to meet identified need (Batterham and Jordan 1997).
The London Health Economics Consortium concluded that the process of elucidating
the views of the local people remained unclear, and that many of the health authorities
and research departments were still experimenting with how to assess local views
effectively (London Health Economics Consortium 1996). They also found that in
many cases the methodologies used were not described in detail. Details of
questionnaires, semi-structured interviews, and lists of prompts for focus groups were
almost universally omitted, unless the focus of the exercise was on the methodology
itself. It was common to list the names of those interviewed, but not the means by
which they were chosen, and hence any related bias.
The points made above by various authors show that it is important to choose a
methodology (or range of methodologies) that is appropriate for the purpose and approach
of a particular health needs assessment. The methods chosen should also be clearly
described. There is no easy, quick fix recipe for health needs assessment. Different
topics will require different approaches. These may involve a combination of
qualitative and quantitative research methods to collect original information, or the
adaptation and transfer of already existing information (Wright ed 1998).
32
2.10 Implementation issues

The continuous challenge within all health services to use finite
resources to the best advantage of patient care is resulting in the need
to ensure that the delivery of care most effectively meets the health needs
of the population (Robins and Rigby 1995).
Needs assessment exercises will inevitably lead to expectations of service delivery.
Wright and Walley (1998), with regard to acting on assessments, observe the hardest
part of any needs assessment is translating the results into policies and practices that
will provide beneficial change. Elsewhere Wright et al (1998) record that one
reason for lack of success is the failure to integrate the results with planning and
purchasing intentions to ensure change. This is restated by Jordan and Wright (1997),
who observed that if the results of needs assessments are to lead to changes in
services to address the needs identified, then adequate attention must be given to
planning and implementation. Using primary care in the UK as an example, Jordan and
Wright conclude that current funding arrangements ... not only fail to acknowledge the
resource implication, but also make response through service development initiatives
difficult.
Health needs assessment
without consideration of the implications for implementation of new health services
(and possibly closure of existing services through reprioritisation) will lead to
disappointment within publicly funded health services, primary care and communities alike.
Another important factor to consider is that involvement of health professionals in
health needs assessments and related population-based approaches may be a
challenge. The traditionally individualistic approach of doctors in particular may be
difficult to reconcile with the utilitarian approach of planners with a population
focus.
This focus implies a
fundamental reappraisal of the doctors role and the balance of power within the
doctor patient relationship (Gillam and Murray 1996).
Either an agreement of parties involved to conduct needs assessments or an empowering
framework, whether legislative or otherwise, seems necessary to avoid some of the potential
conflict where the reasons for or potential results of such assessments are unclear. In a
challenging editorial, Hannay (1993) encourages primary care and public health to
work together. The new emphasis on health promotion provides both groups of
doctors to discover their common roots, and benefit the community.
With regard to the benefit realised by the community, DHBs must acknowledge that
health needs assessment exercises will raise expectations in the minds of the
public for implementation of new services. In this respect DHBs will have a difficult
task to perform. Health funding is a finite resource that will be allocated to each
Board through the Population-Based Funding Formula (PBFF). For some DHBs this
will mean that new additional funding will become available, above current levels of
spending. For them, investment in new health services will be a matter of purchasing
according to priorities using the prioritisation framework (see Chapter 4). In such
circumstance less disinvestment may occur. However, other DHBs may experience
considerable pressures to prioritise existing services because of present total over
investment and therefore reduction of funding through capitation using the PBFF.
Government, DHBs and the public will want to ensure that transparent processes occur.
The expectations of the public surrounding implementation
33
issues following health needs assessments are important and will have to be
carefully considered.
34
Chapter 3: Prioritisation Stage of

Health Needs Assessment
3.1 Background
Prioritisation is the last stage of the process of health needs assessment. Consequently
it should be regarded as an integral component of needs assessment, just as
implementation is a necessary consequence. Prioritisation compares different needs,
considers service priorities at the margin, evaluates the costs of meeting needs, and
finally ranks needs in preference order, usually for purchasing purposes. There are a
number of approaches to priority setting. These include Delphi approaches, consensus
techniques, principles-based approaches, cost-utility analysis, and programme budgeting and
marginal analysis.
Principle-based prioritisation is decision-making guided by a set of values or principles
held to be important by the society in which the decisions must be made. Attempts to
put in place principle -based prioritisation frameworks have been made in Sweden,
Holland, USA, Canada and New Zealand (Swedish Parliamentary Priorities Commission
1995; Government Committee on Choices in Health Care 1992; Honigsbaum 1991;
National Forum on Health 1997).
The case for a value and principle-based approach to prioritisation or
rationing has been made by a number of commentators (Eddy 1994;
Ovretveit 1997; Lenaghan 1997; McKee and Figueras 1996). Two key
themes consistently emerge from the deliberations:
1.
A principled approach to prioritisation involves moral controversy

surrounding the principles themselves.
2.
Controversy surrounds where the legitimate locus for making

prioritisation decisions should rest.
These themes are evident in the New Zealand experience with

prioritisation (Health Funding Authority 2000e).
New Zealanders have historically taken a social equity approach regarding access to
health and health care services, prioritising on the basis of an underlying set of moral
principles rather than a market-driven or economic approach. This, coupled with
constant health reform, linked to indecision regarding centralisation or decentralisation,
has suggested that New Zealanders have grappled with the issue of central control and
want a moral voice regarding access to publicly funded health services.
This HFA reports the historical experiences, both international and national, including
those of the National Health Committee, Midland Health (199798) and the current
approach of the HFA (2000e). These are now described below.
35
3.1.1 The National Health Committee

In 1992, following structural change, responsibility for conceptual work
regarding prioritisation was assigned to the Core Services Committee, now the
National Health Committee. The terms of reference for the Core Services Committee
were as follows:
The basic goal of the Government, in setting up the Committee is to
receive independent advice on what health services and disability support
services the Government should ensure are purchased with due respect to
its limited fiscal means in order that people have access to effective
services on fair terms.
These core health and disability support services should reflect the
diverse needs and values of the populations being served. Public health
professional and other relevant professional consultation, and
consultation with those with expertise in services for people with
disabilities should be extensive.
Key tasks
The Committee is to advise the Government on core health and disability
support services to which the public should have access on fair terms. It
should:
Seek to identify current services in terms of their costs, their

efficiency, the range available, their utilisation, and any
deficiencies or variations in their provision.
Assess the effectiveness and relative benefits of these services and

the potential impact of any recommended changes.
Consult with the public and with health professionals and other
relevant professionals about the services currently provided and
their distribution, and seek views on which services the Government
should ensure are purchased and on any desired changes in the
distribution of services or their terms of access.
Recommend annually to the Minister of Health which core health

and disability support services should be purchased, how they
should be distributed and the terms of access on which they should
be available.
Recommend periodically to the Minister of Health any changes

necessary in the future processes for advising the Government on
core health and disability support services (National Advisory
Committee on Core Health and Disability Support Services 1992).
As Cumming (1997) comments, the Committee was given little guidance on how
to approach this enormous task. Options for defining a core were set out in reform papers
and in a discussion document released in la te 1991 (Minister of Health 1991). The
options considered included a general positive list of services in the core, a small
negative of services not in the core, and a priority-ranked approach such as that used in
Oregon in the United States (Oregon Health Services Commission 1991). This
latter approach to
36
prioritisation, instituted following Oregons withdrawing Medicaid coverage for

organ transplantation, used a method based on a costutility formula but also incorporated
public attitudes and values. Using an explicit process involving public consultation, the
Oregon Health Services Commission completed the ranking on 714 conditiontreatment
pairs which could be publicly funded, from a total list of 1600 such pairs (Dixon and
Welch 1991). The Oregon approach was eventually discarded by that state following
criticisms from the public and physicians.
The Committee also considered a range of other options (National Advisory Committee on
Core Health and Disability Support services 1993a), including the use of qualityadjusted life-years, and an approach adopted in the Netherlands. This latter used the
following criteria: care regarded as necessary from a community perspective; effective
care; efficient care; and care that cannot be left to individual responsibility
(Government Committee on Choices in Health Care 1992).
In his foreword to the Core Services Committee Report 1993/1994, the Hon. Simon
Upton situated the responsibility for priority setting in the community with the Core
Services Committee, alongside health professionals and others:
The setting of priorities in health and disability support services requires
us to decide the values that society places on certain services and
treatments. It is an exercise that must involve all sectors of society it is
no longer appropriate or fair for politicians, managers, or health
professionals to be expected to make these decisions on our behalf
(National Advisory Committee on Core Health and Disability Support
Services 1992).
The Committee rejected the positive list of core services and the Oregon-style
approach following extensive public consultation. It argued that a simple listing approach
was unlikely to be fair, as it was not possible to state that some services would be
ineffective all of the time. Nor could such a list take account of the differing degrees of
benefit expected from services for different patients (National Advisory Committee on
Core Health and Disability Support Services 1994).
The approach taken by the Committee has been to make gradual changes to the
implicit core, ie, those services already funded.
It recommended four criteria
that had been affirmed during a process of public consultation:
benefits and effectiveness
value for money
fairness
whether or not the services available are consistent with communities values and
priorities (National Advisory Committee on Core Health and Disability
Support Services 1993a).
The Committee proceeded to work on promoting increased awareness of services that

met the above criteria. This was la rgely done by publishing guidelines that were
generally evidence-based clinical guidelines for best practice.
37
Following the Committees advice to the Minister regarding criteria for purchasing,
the Ministry of Health proposed a set of purchasing principle s to guide the actions
of the Regional Health Authorities: equity, efficiency, effectiveness, acceptability, safety
and risk management (Minister of Health 1995).
3.1.2 Midland Health (199798)

Midland Health, on behalf of the four Regional Health Authorities, formed a
Prioritisation Team to develop the prioritisation work further.
It reaffirmed the
necessity for a prioritisation framework that would provide a rigorous, explicit,
ethical and transparent process based on an agreed set of principles to guide the
setting of priorities and allocation of resources (Health Funding Authority 1998f).
The
Prioritisation
Team
recommended a principles-based approach to purchasing by the HFA that should
set priorities and allocate resources to fund services that:
provide benefit (effectiveness principle)
ensure access is fair, by offering equal opportunity for access for groups or
individuals who have similar levels of need (equity principle)
recognise the Crowns objectives for Mori health and its obligations under the
Treaty (Mori health principle) (Department of Health 1992)
are consistent with the needs and values of communities (acceptability principle)
are the best value for money (efficiency principle).
These principles were further modified by the Prioritisation Team that formed under
the auspices of the Corporate Strategy group of the HFA, resulting in the May 1998
report (Health Funding Authority 1998d).
3.2 Health Funding Authority prioritisation

process
The HFA Board agreed that in making decisions, determining priorities and
allocating resources, it would give regard to the following decision-making principles:
effectiveness
cost
equity
Mori health
acceptability.
In order to improve allocative efficiency for publicly funded services, the HFA developed
a prioritisation process based on these principles. It centred on an economic framework
using costutility analysis. However, following consultations with stakeholders and
expert groups
38
the proposed process was modified. The revised process consisted of programme
budgeting and marginal analysis (PBMA), incorporating economic costutility analysis
(CUA), and taking into account the prioritisation principles of equity, Mori health,
acceptability and other health and disability gain priority areas (Health Funding Authority
1998d).
The process is described in further detail by the HFA (Health Funding Authority 2000e)
and has been described by Ashton et al (2000). The latter describe the process as
involving seven steps (Figure 5).
Figure 5:
The seven steps in the process

Step 7:
Step 6:
Step 5:
Evaluate process
Make initial purchasing decisions, then

consult and finalise decision
Assess impact on equity, acceptability; ensure

consultation with Mori
Step 4:
Step 3:
Obtain costs for the bundle of marginal services
Collate evidence on effectiveness and, where possible, calculate

QALYs
Step 2:
Step 1:
Identify marginal services for analysis plus numbers and kinds of patients
receiving services
Consult with clinicians, service managers and consumers
Source: Ashton et al 2000

Note: QALY = quality-adjusted life years.
Step 4 also includes flow-on costs and estimating cost effectiveness of programmes.
The final generic process accepted that costutility analysis could be used as an
effective technical tool, but was not the only tool available, and had limitations (as do
other economic tools).
3.3 National Health Committee review of the

HFA process
The National Health Committee, concerned about the HFA approach, commissioned
a review. Ashton et al (1999), in reporting to the National Health Committee in
February
39
1999 on the HFAs prioritisation approach, stated that they were broadly in agreement
with the set of principles proposed to determine purchasing decisions. However, they
noted that:
The key questions in relation to these principles are (i) the means by
which each is defined and operationalised and (ii) how the prioritisation
process incorporated the principles: the relative weight assigned to each,
how trade-offs between principles are to be dealt with, and whether any
of the principles provides a veto over the priorities suggested by the
others.
The decision of the HFA to use CUA as a starting point upon for how purchasing
decisions would be made was arguably a controversial decision according to Ashton et al.
Support for this notion comes from Australian research on the opinions of a cross-section
of the public, which found little support for the idea that the objective of the health services
is to maximise the number of quality-adjusted life-years (QALYs) gained where the
consequence is a loss of equity and access to services for older people and for people
with a limited potential to improve their health (Nord et al 1995). However as Mooney
(1998) notes, there remains a concern with Nord et als research that the respondents
simply did not comprehend the concept of opportunity cost. The Swedish
Parliamentary Priorities Commission (1995) supported Nords view, which argued that
cost-effectiveness be ranked third as a principle for priority setting in health care in
Sweden, and that it should only be applied when comparing methods for treating the
same disease.
It was noted by Ashton et al (1999) that CUA remains in the HFAs August 1998
document as the key means by whic h the principles of effectiveness and cost will be
addressed (Health Funding Authority 1998e).
Cost-effectiveness acts as a
necessary but not sufficient condition in decision-making. The principles of equity and
acceptability are to be addressed as subsequent evaluations. Mori health issues will be
addressed at every level of the system to ensure that equity is specifically addressed. In
its full expression, the HFA prioritisation approach involves a CUA combined with
analysis of equity, Mori health and independence and acceptability impacts. In a
subsequent editorial following the Second International Conference on Priorities in Health
Care in October 1998, Klein (1998) stated:
once we acknowledge that setting priorities is inescapably a political
process it involves making painful decisions socially acceptable and
mobilising consent among both the health professionals who have to
implement them and the public who are affected by them we can turn to
devising the appropriate mechanisms for doing so.
With reference to the above statement, Ashton et al (1999) commented that:
In this context, we believe that the technical approach proposed by the
HFA (Cost Utility Analysis, a form of economic analysis) has merit. We
also believe, however, that the important role that values play in assessing
priorities and the international experience suggest the need for caution in
attempting to apply CUA across the board. In addition, we would argue
that the process of setting priorities including engaging stakeholders
is as important as the technical aspects of CUA.
The HFA approach was ambitious, but Ashton et al (2000) concluded that:
40
The HFA proposal represents an important step in the right direction

towards improving the allocative efficiency of health services. However,
it will be important to proceed carefully and explicitly and to pilot the
proposed process openly. The process and its costs should also be
documented, monitored and evaluated. Outstanding issues that need to
be addressed include:
Clearer definition of the principles of equity, acceptability and

Mori health
Clarification of trade-offs between the five principles
Development of a clearer framework for identifying marginal

services
Clarification of which instruments and whose preferences should be

used in the estimation of QALYs
Assessment of the importance of non-health outcomes that cannot or

are not captured by these measures
Development of procedures to be taken in cases in which

effectiveness, cost and other information are absent or inaccurate
Development of some process that ensures that decisions at other

levels of the system are consistent with the decision-making
principles and practices of the HFA.
The HFA has been piloting the principles-based decision-making framework during
1999 and 2000, including the use of both CUA and PBMA in specific areas. The
process of application of the framework and maintaining the pool of prioritised initiatives
is described in careful detail by the HFA (Health Funding Authority 2000e). In
addition, the learning experiences gained as a result of using the framework are also
described. It is hoped that the Ministry of Health will continue developing the
prioritisation framework to improve it further.
It should be emphasised that the prioritisation process does have limitations, and that
these are recognised, but that as yet no better system has been devised and indeed all
other processes used elsewhere have limitations. The HFA has found that this is a
usable methodology for allocation of new monies, but that it is not universally
applicable for all allocation purposes. In particular, it has been used with personal health,
using CUA as the economic tool, and within public health, where the PBMA approach was
used to prioritise in 1999. There are concerns within disability support services because a
CUA approach does not adequately capture QALYs. Consequently, as yet the full
prioritisation approach has not been used for disability support services prioritisation.
While excellent progress has been made with the HFA prioritisation framework,
and valuable lessons learnt, there remain a number of areas for future development of
the framework. It is hoped that the Ministry of Health and DHBs will continue to resolve
these issues. Copies of the report have been sent to DHBs and it is understood that the
work is now ready for wider public comment. The report meets the prioritisation
performance measure for the final quarter of 1999/2000 in the Funding Agreement
between the HFA and the Ministry of Health.
41
3.4 Programme budgeting and marginal

analysis
3.4.1 Introduction
The traditional approach to needs assessment, relying on epidemiological information
alone for prioritisation, has been criticised for its lack of impact on purchasing
(Stevens and Gabbay 1991). Measuring the total burden of disease or illness in a
population is not sufficient. What is required is a way to match information on the
costs of health care interventions to the benefits produced so that purchasers can gain
the greatest benefit from a defined budget.
Programme Budgeting and Marginal Analysis (PBMA) is a health economic approach
to prioritisation. The combined techniques can be used by purchasers to direct resources
so that health care service delivery has a maximum impact on health needs of the
local population (Donaldson and Mooney 1991; Donaldson et al 1995; Mooney 1984).
The technique of programme budgeting was briefly used by Mooney (1977) but went
out of favour until it returned combined with marginal analysis (Donaldson and Mooney
1991).
The programme budgeting approach describes the current spending pattern of a
purchaser, along with where that spending occurs among different groups in the
population. These groups may be described by disease classification, by disability, or in
any other meaningful way (Davis et al 1995; Brambleby 1995). However, programme
budgeting on its own proved to be of limited value as it is essentially a descriptive
technique and is not designed to offer guidance on the way in which current spending
patterns could be modified to achieve allocative or technical efficiency. It was not
until marginal analysis was added that it became possible to use the programme
budgeting framework to explore ways of improving technical effic iency by
understanding the cost-effectiveness of inputs (Cohen 1994; Twaddle and Walker
1995).
Experience with the use of PBMA is reported from overseas (Miller et al 1997; Mooney et
al 1997; Peacock et al 1997; Ruta et al 1996); and in New Zealand (Sceats et al 1995;
Bohmer 1996; Cumming et al 1996; McKean et al 1996; Vaithianathan 1996). By means
of example, Ruta et al (1996) showed how PBMA can be used to formulate a
purchasing strategy for child health services. They reviewed policy documents, used
traditional epidemiological methods of needs assessment to conduct a health profile for
children in Tayside, UK, formulated a programme budget matrix, obtained the
views of health professionals and parents, conducted a review of research evidence on
effectiveness and cost-effectiveness. The child health strategy working group then
reviewed all the available information and prioritised for service
development/investment and for service organisation/resource release. They
concluded that the approach taken resolved many of the conflicts and difficulties facing
purchasers. This example is shown as a case study in Chapter 5.
42
3.4.2 The PBMA method

This has been well described by Posnett and Street (1996), and what follows
summarises their approach.
Programme budgeting
Decisions regarding spending are dominated by the need to establish contracts to
purchase services. Budgets are typically summarised in the form of a table, in which total
expenditure is classified by hospital and specialty (see Table 7).
Table 7:
Specialty-based contracting
Specialty
Provider
Hospital A
Hospital B
Hospital N
Total
General medicine
$SGM
General surgery
$SGS
Trauma and orthopaedics
$STO
Total
$TA
$TB
$TN
($TA.N) = ($SGM.TO)
Source: Posnett and Street 1996
The problem with this approach is that it is difficult to relate expenditure to the impact
of that expenditure on the health needs of the population. The result is that strategic
planning can be more influenced by the interests of providers rather than health needs.
Programme budgeting allocates costs by programme, rather than provider, and focuses
on inputs. An example of a programme budgeting matrix is shown in Table 8.
Table 8:
Programme budgeting
Programme
Inputs
Hospital
Community
Primary
Total
Mental health
$PMH
Circulatory system
$PCS
Respiratory system
$PRS
Total
Source: Posnett and Street 1996
$IH
$IC
$IP
($I
.P)
= ($PMH.RS)
43
Programme budgeting provides an explicit statement of expenditure by programme

and therefore implicitly records the purchasers priorities in spending between
different population groups. Over time changes can be made between programmes, or
population groups, to reflect more accurately the health needs of the population.
In practice, information on the impact on programme spending on health status is unlikely
to be available for all (or most) of the programmes, nor presently can the effort to obtain
it be justified.
However,
with time more information will become available.
Programme
budgeting is particularly useful where incremental change in the balance of spending is
being considered. The effort to gather the necessary information to consider the impact
of such change on health status could well be justified. It may also be possible to collect
information regarding activity within a programme (such as number of patients
treated, number of episodes of care). Ideally, spending would be related to outcomes.
Programme budgeting, by highlighting the input mix within a programme,
allows consideration of the technic al efficiency of that programme.Technical
efficiency is achieved within a programme if it is not possible with the same expenditure
to gain further improvement in health status generated by that programme. Technical
efficiency requires two conditions to be met.
Each output should be produced at least cost.
The mix of inputs within the programme must be optimal (for example, balance
of spending between secondary, primary and community care).
The technique of marginal analysis has been developed primarily to address the
second requirement for technical efficiency.
In summary, the programme budgeting phase is where a group of decision-makers build up
a picture of a programme by collecting data on cost, outputs and outcomes. This gives
a picture of how resources are presently spent.
Marginal analysis
One or more programmes are selected for marginal analysis and all the inputs to
those programmes are specified. Estimates of the current levels of activity and spending
are also collected.
The aim is to evaluate options for reallocations within or
between the programmes. Since the aim is to achieve technical efficiency, the overall
exercise must be resource neutral (total spending remains unchanged). If additional funds
are available, then PBMA can be undertaken to obtain greatest gain from their use.
The marginal analysis phase consists of several steps. Firstly, consideration is given to
the additional services that could be purchased if additional funding were available, and to
those services that would be reduced if less funding were available.
The use of a group of experts to generate options for resource shifts within a
programme is a common current approach (for example, the New Zealand Health
Strategy planning process uses a group of experts to prioritise resource allocation
effectively to 13 priority areas, although no resource is attached to their prioritisation).
Given the usual resource
44
neutrality constraint, these options must include proposals for reducing

expenditure (disinvestment) as well as those for new expenditure (investment).
Secondly, the likely costs and outcomes of such changes (length and quality of life)
are considered for individuals in the programme using available evidence on
effectiveness and cost-effectiveness. Costutility analysis forms part of this process.
The use of best evidence from the literature is another way of incorporating users views
to ensure that the public participate in the process.
In the third step, decisions are made about which services to increase and which to
reduce, based on the relative costs and benefits to be obtained from such resource shifts
(Mooney et al 1992; Donaldson et al 1995; Cumming and Scott 1998). There is scope at
this point for public consultation. If it is possible to find a mix of options that will
produce a positive impact on outcomes overall, adopting the changes implied by this
mix will improve the technical efficiency of the programme.
The composition of the expert group is important because of the potential pitfalls.
Including local clinicians runs the risk that the exercise is dominated by providers
with vested interests. Where consumers are included there are risks that they may be
uninformed, or ill informed, or that their views may not be representative. Some
professional groups are readily dominated by professional hierarchies within the health
service (Cohen 1994). In some cases, different approaches have been taken to obtaining
the views of the public by using surveys (Donaldson and Farrar 1993), secret ballot
(Cohen 1995) or deliberative polling (Mays and Hand 2000).
Different approaches have been used to help groups make decisions on prioritisation.
In some exercises the group is asked to suggest between five and ten areas where
additional expenditure is judged to be the most beneficial, and a similar number of areas
where savings could be made with minimal impact on patient outcomes (Madden et al
1995). In others, the group is asked to imagine that a fixed sum is to be reallocated
between services (Donaldson and Farrar 1993; Cohen 1995). Using this approach, the
group is asked to prioritise areas for investment and disinvestment, for greatest positive
impact on health outcomes.
It is generally accepted that this is the hardest stage of PBMA. Participants are commonly
unwilling to consider anything other than service expansions and some refuse to take part in
the exercise at all. In addition, it may be that the options chosen by the group may not
be the ones that result in the greatest improvements in efficiency. It should also be noted
that PBMA focuses on marginal shifts within and between programmes, and
observations regarding marginal costs, and that these costs are often difficult to
measure. However, PBMA allows consideration of national policy, local epidemiology,
current spending, and the public views as to how much spending can be changed. The
relationships between the various components that together go toward PBMA are shown
in Figure 6.
While this figure focuses on PBMA, it is consistent with the approach taken in Figure
1. Some practitioners of PBMA believe that it is not necessary to produce programme
budgets before conducting the marginal analysis stage (Donaldson et al 1995; Cohen
1995; Craig et al 1995; Donaldson 1995). They essentially argue that the generation of
options by an expert group requires a shared understanding of current practice, patterns
of patient flows and the current distribution of spending (rather than programme
budgets); and that the
45
programme budgeting does not present the range of options available or the way
that patients relate to services. These obstacles can be overcome by presenting this
additional information to expert groups at the marginal analysis phase.
Figure 6:
A strategic framework for determining purchasing priorities
Epidemiology-based
needs assessment:
socio-demography,
mortality, morbidity
Review of national
and local policy
Statement of
philosophy,
long-term goals
Consumer/
public views
Determining
purchasing
priorities:
identifying margins
for change
Programme budget
matrix:
cost and activity data
Health professional
views
Research evidence
of effectiveness and
cost-effectiveness
Source: Ruta et al 1996
Posnett and Street (1996) suggest an approach that is designed to capture the process
of health care for a particular patient group (using the example of coronary heart
disease patients) using a flow diagram (or decision tree) in which all relevant options are
examined prior to evaluation. The flow diagram and associated programme matrix can
be used to establish current practice, current patient flows, activity, expenditure and
range of options for evaluation.
Relevance to New Zealand

While PBMA has gained some acceptance there are key issues that require careful
consideration, such as the time taken for implementation, difficulties in allocating
service interventions, reluctance to identify services that may be reduced, difficulties in
reaching consensus and priority setting, and difficulty in implementing the results of
the process. However, these are not too dissimilar to the limitations of all methods of
setting priorities.
In their assessment of this method Ashton et al (1999) commented:
PBMA is still under development as a tool for priority setting in health
care. Given the need to spend time on getting participants to understand
the process, and given the complex process issues involved, we
46
recommend that the HFA proceed carefully in using PBMA in New

Zealand, and consider using it to assist in making decisions within
services in the first instance.
The HFA has used PBMA in personal health and public health. However, it should
be noted that there is little experience with the use of PBMA approaches in disability
support services and Mori health services. Prioritisation of these services may well be
possible using a PBMA approach, since this is only one step of a principles-based
approach recommended by the HFA, for example, PBMA based on child health
services would include all possible services, including public health measures.
The system of prioritisation suggested by the HFA has argued for a PBMA approach, with
a principles-based approach in addition, largely using cost and effectiveness through
CUA. One of the other principles was that of acceptability, which was described as
political and social acceptability (p.13). This potentially allows the principle of
acceptability to override any other prioritisation process and so effectively gives
acceptability the power of veto. If PBMA were to be used in any significant way, it
appears logical to determine issues of acceptability at the outset, before time and
effort are expended on the balance of the prioritisation process. It has been
observed that the inclusion of acceptability risks becoming a kind of formalised
escape clause to avoid contentious decisions, unless it is based upon some clearly
articulated and agreed set of precepts regarding justice or human rights (Ashton et al
1999). However, the alternative is a contentious set of decisions that are hard to
implement.
Health services for Mori will require consultation on Mori health needs. A
PBMA approach is quite appropriate, as it is possible to build any level of consultation
into PBMA. In order to address issues of equity, the HFA proposed that it would:
... favour services that tend to reduce inequitable disparities in health
status, even if those services do not improve overall health status within
the larger population as much as some other combination of services
might. Thus we are willing to sacrifice some allocative efficiencyin
order to reduce inequitable disparities in health.
The remaining question is one of how such inequities in health status would be
prioritised within the framework as a whole. In any event, such a move to equity of
outcome is a shift away from the principle of equity of access that has underlined most
health policy in New Zealand (Scott et al 1986; Peacock et al 1998). Issues to do with
the definition of equity arise under such circumstances, along with weighting of
outputs (QALYs) for ethnic groups. However, such an approach would be consistent
with the Governments policies for reducing health inequalities for Mori (Minister of
Health 2000d). However, a more potent argument is that the issue of equity must
essentially relate to equity of health outcomes, and that the issue of equity of access is
secondary to achieving that goal.
Conclusions
Prioritisation of health service delivery is a process that should systematically, explicitly
and transparently define the use of resources for maximising health gain. This
implies little consideration of distributional issues. However priorities can be set
incorporating an equity-
47
efficiency trade-off. The process should be principle -based and value-driven, using
robust methodologies that take account of proven instruments for costutility analysis
and guided by informed judgement. PBMA offers an approach for DHBs.
However, caution should be advised in the use of any technical fix in isolation
from judgement and consultation. There is a range of other methods of priority setting that
can be used. These have been discussed above. Current ring-fencing arrangements
between personal health, mental health services, disability support services, Mori health
and public health do not allow redistribution of resources between these service groups.
In particular, disability support services are in a legally binding resource boundary
(Non-Departmental Output Class: NDOC). Within these health budget areas, allocation of
resources according to need is common, using needs analysis and prioritisation.
Consultation with health and disability support providers, Mori and the community, as
part of the prioritisation process, will need to be a feature of resource allocation in the
future. Involvement of stakeholders will be important to achieve analyses and the
implementation of the results of the prioritisation process.
3.5 Community consultation

3.5.1 Observations on the legislative framework
The mandate for community consultation is embodied in the four-fold purpose of the
New Zealand Public Health and Disability Act, where it is stated that the purpose of the
Act is to:
(c)
Provide a community voice in matters relating to personal health

services, public health services, and disability support services ...
(iii) by providing for consultation on strategic planning.
The intent of the Government in regard to community consultation on health care

service delivery need is apparent in a Cabinet paper in which the roles of DHBs are
considered:
To achieve those objectives District Health Boards will: (a) regularly
assess and monitor the health and disability service needs of their
populations ... (e) consult and exhibit a sense of social responsibility by
having regard to the interests of the communities they serve (Minister of
Health 2000c).
Experience in the UK in the National Health Service has shown that external inputs
to health needs assessment and the prioritisation of health services has been perceived as
one way of addressing the democratic deficit in the health service (Jordan et al 1998).
While such a deficit will be met in part by the election of DHBs, there is further
evidence of the significance attributed by the Government to community involvement:
a Cabinet Social Policy and Health Committee memorandum states that one goal of the
new arrangements is to increase community say over health and disability services
(Minister of Health 2000f).
48
The establishment of DHBs, election of the majority of DHB board members, and
transfer of funding/functions to those boards (Minister of Health 2000b, c, e; Crown
Company Monitoring Advisory Unit Health Group 2000) is a significant move towards
providing a community voice in health care needs assessment and service delivery at
the district and community level. There are requirements for consultation with, on the one
hand, the general public regardless of whether or not they are current patients or users, and
on the other, with current users regarding needs and priorities (Jordan et al 1998).
3.5.2 The HFA approach to consultation a tool for DHBs

In February 2000 the HFA formalised its policies in a document entitled Health
Funding Authority Consultation Obligations and Guidelines (Health Funding
Authority 2000c). The document sets out the principles and meaning of
consultation, Treaty and legal obligations, and issues referring to the process of
consultation. It represents an invaluable resource for DHBs and as such will assist with
the consultation process.
Of the basic principles established by the HFA that apply to the consultation process,
the following are of particular importance.
Consultation assumes that proposals being consulted upon have not

already been finally decided.
The HFA will listen to participants with an open mind and value
everyones contribution.
The HFA will consult with Mori in accordance with the HFA Mori
Health Policy.
Consultation planning, processes and procedures will be publicly

explicit, appropriate for the purpose, professionally developed and
implemented.
All documentation will be honest and easily understood.
Consultation will clearly establish parameters and expectations

including what has been already decided.
All ideas and feedback will be considered when decisions are being
made.
Consultation will reflect the values of respect and accountability to

communities.
Consultation is a process that is different from notification, negotiation or agreement. It

has been defined in law as being more than notification but something less than
negotiation and agreement.
Consultation must be allowed sufficient time, and genuine effort must be
made. It is to be a reality, not a charade. The concept is grasped most
clearly by an approach in principle. To consult is not merely to tell or
present. Nor, at the other extreme, is it to agree. Consultation does not
necessarily involve negotiation toward an agreement, although the latter
49
not uncommonly can follow, as the tendency in consultation is to seek at

least consensus ...
Consulting involves the statement of a proposal not yet finally decided
upon, listening to what others have to say, considering their responses
and then deciding what will be done.
Implicit in the concept is a requirement that the party consulted will be (or
will be made) adequately informed so as to be able to make intelligent and
useful responses. It is also implicit that the party obliged to consult, while
quite entitled to have a working plan already in mind, must keep its mind
open and be ready to change and even start afresh. Beyond that, there
are no universal requirements as to form ... (per J McGechan adopted by
the Court of Appeal in Wellington International Airport v Air New
Zealand [1993] 1 NZLR 671 at 675).
While it may be tempting to view consultation as an exercise to confirm a preformed position, the legal view is different. The consultation process consists of setting out
a clearly defined proposal, which has not yet been finally decided upon; providing
sufficient information about the proposal so that meaningful responses can be made,
with adequate time being allowed for preparation of responses; proper evaluation of all
responses received, by persons who have not predetermined the outcome; and final
decision-making on the proposal.
The New Zealand Health Strategy Discussion Document cites a number of reasons for
ensuring that consumers, communities and providers are involved in strategy or
programme development. These include:
50
democratic participation: taking into account different perspectives
partnership and collaboration: fostering shared ownership of

solutions to problems, and therefore achieving more co-ordinated,
committed action
equity and fairness: fostering shared understanding, and arriving

at equitable solutions
accountability: from those who design and provide services to those

who use them
acceptability:
acceptable
ensuring the rights of consumers are upheld
ensuring provider, community and consumer input is valued
taking advantage of a range of expertise
acknowledging and reflecting bicultural values
adopting a holistic approach: considering issues in relation to

communities, consumers and providers, and arriving at practical
and effective decisions (Minister of Health 2000d).
fostering
development
of
solutions
that
are
The process of consultation by DHBs will involve providers and users of services, and
the community, which will be able to have input into major decisions taken by the Boards.
3.5.3 Consultation with Mori

DHBs are required to consult with Mori, including Mori exercising mana whenua in
order to enable Mori to participate in and contribute to strategies for Mori health
improvement (refer NZPHD, Cl 18 1 (c), and see Appendix Five) (Minister of Health
2000e).
The process for consultation with Mori and non-Mori is well described in the
HFA consultation obligations and guidelines policy document (Health Funding Authority
2000c), and DHBs are referred to this document for advice.
The HFA Mori health policy states that:
The Treaty of Waitangi establishes the unique and special relationship
between iwi Mori and the Crown. As a Crown agency the HFA
considers the Treaty of Waitangi principles of partnership, proactive
protection of Mori health interests, co-operation and utmost good faith,
to be implicit conditions of the nature in which the internal organisation
of the HFA responds to Mori health issues (Health Funding Authority
2000c, p.6).
This interpretation of the Treaty of Waitangi obligations in respect to health is the basis
of the relationship and the nature of consultation with Mori.
Whereas in the
past the relationship has been with the HFA on behalf of the Crown, the relationship will
transfer to DHBs. In this way the Bill provides for a special relationship between the
DHBs and Mori, requiring DHBs not only to consult with Mori from the outset but
also to be cognisant of the impact of new health policies on them.
In the current health environment in New Zeala nd there is a clear need for meaningful
community involvement in health decision-making at all levels. However, members
of DHBs should be aware of the kind of situation described by Hulse, a councillor on
the Waitakere City Council. She claimed that while consultation was a buzzword of the
1980s and 1990s, it has become debased, with the result that people have become
sceptical that their input will actually make a difference (Hulse 1999). Her contention
is that effective community interaction in health will be distinguished by clarity of
objectives and roles, inclusiveness, timeliness, innovation in communication and Treaty
of Waitangi consideration with Mori involvement.
3.5.4 Consulting the public about health service priorities

general comments
This next section briefly reports some general comments regarding consultation with
the public in health service delivery. Various methods have been used for public
consultation. These are described in Box 6.
51
Box 6:
Methods of public consultation
Citizens juries participants are selected as representatives of public or local

opinion. Juries sit for a specified length of time, during which they are presented
with information to help in decision making. Typically, experts give evidence and
jurors have an opportunity to ask questions or debate relevant issues (Lenaghan et
al 1996). (Compare this with deliberative polling, as explained in Mays and Hand
(2000)).
User consultation panels consist of local people selected as representative of

the locality or population. Typically, members are rotated to ensure that a broad
range of views is heard. Topics for consideration are decided in advance and
members are presented with relevant information to encourage informed
discussion. Meetings are often facilitated by a moderator (Bowie et al 1995).
Focus groups typically, semi-structured discussion groups of 68 participants

led by a moderator, with focus on specific topics. Debate and discussion are
encouraged (Bowie et al 1995).
Questionnaire surveys can be postal or distributed (in the surgery, for example).
This structured or systematic means of data collection allows information to be
collected from a large sample of respondents and the relationship between
variables to be examined. Most appropriate when the issues relevant to the topic
being investigated are already known in some detail.
Opinion surveys of standing panels standing panels are large, sociologically

representative samples (typically 1000 or more) of the population in a health
authority; they are surveyed at intervals on matters of concern to the authority.
There is usually a replacement policy aimed at ensuring that individuals do not
serve on the panel indefinitely.
Source: Jordan et al 1998
Consultation with the public can be considered from two perspectives. A distinction
needs to be made as to whether respondents are provided with information, or
whether the respondents are able to engage in any discussion or deliberation in arriving
at their own views (Mort et al 1998). These dimensions define the matrix in the Table 9.
Table 9:
Approaches to consultation on health care priorities

Informed
Deliberated
Citizens juries
Uninformed
Focus groups
User consultation panels

Undeliberated
Questionnaire surveys with written

information
Opinion surveys of standing panels/

one-off questionnaires
Source: Jordan et al 1998
Experience from the UK in listening to local voices echoes the importance of the
community voice being heard (Peckham 1994). Key shifts in health professionals views
are required. Paramount is the need to value the lay opinion and recognise that what
people have to
52
say is of value both in terms of what is being said, but also in respect of the
positive experience of being valued and involved (Hallett 1987).
The value and importance of acknowledgement of patients and their organisations
is underscored by Wilson (1999) in the context of people living with long-term
medical conditions. Patients require access to good quality, evidence-based information
so they can take an active part in decisions about their health care (Shepperd et al 1999).
Communities have a right to participate in the decisions that affect their health, but:
It is politically tempting for health planners to seek endorsement from
communities for planners intentions ... but in practice, they should
recognise the danger in sublimating community interests in an
orchestrated process of consensus building and priority setting, which
has a high risk of having its deliberations ignored (Hawe 1996).
53
Chapter 4: Case Studies in Health

Needs Assessment
4.1 Porirua City Health and Disability Report
and Plan
This is an example of a global health needs assessment. It was commissioned by the
previous Minister of Health to improve health and disability outcomes for the people
of Porirua City (Porirua Kapiti Healthlinks Project 2000b). A similar project was
undertaken for the people on the Kapiti Coast (Porirua Kapiti Healthlinks Project
2000a). The report contains recommendations to the Minister of Health set out in
health and disability plans. Importantly, it should be noted that this health needs assessment
is based on a local authority (Porirua City), and that it does not endeavour to prioritise the
list of health service needs that arises. It is therefore different in two respects from
DHB-based global health needs assessments. However, there are sufficient similarities
for it to be worth considering as a case study.
In 1999 the local authority approached the then Minister of Health concerned about
the health and disability outcomes of the people of Porirua City. Funding was obtained
and a partnership, known as the Healthlinks Project, was formed between the Council,
Mori, Pacific peoples and the community. The Porirua Project Team gathered
information about peoples health status, health and disability services and their use from
a variety of sources. Gathering information on health status and health service use
involved collecting and analysing information from the New Zealand Health
Information Service, Health Benefits Limited, the HFA, Statistics New Zealand and
the
Porirua
City
Council.
Additional information was collected directly from service providers, and additional
national data (often from Ministry of Health publications) was collected to indicate
trends in service use and health risk factors that might apply to Porirua.
Meetings and formal discussions were held with the general public, health and
disability providers, community groups, and organisations with an interest in healthrelated issues. Peoples views were sought regarding problems with existing services or
service gaps, local priorities and how to address these, and services that were working
well. In addition, the Project Team held one-on-one interviews and informed discussions
with providers, received written comments from providers, and asked providers to
complete a questionnaire on service provision and gaps in provision. Extensive public
consultation was undertaken to ensure that the views of the public, providers and
community groups were fully canvassed.
Hard information regarding service use, health status and views from the public
and providers helped the community and the Healthlinks Project identify what was
needed to improve health and disability outcomes in Porirua.
Specifically,
demographic and epidemiological information was collected on the full range of
variables, listed in 56 tables
54
and 20 figures, with data collected in age bands where appropriate. One example of such
information is shown in Table 10 below:
Table 10:
Numbers and standardised rates of avoidable hospitalisations per 10,000 1994

98
Ambulatory sensitive
Raw
Case-mix-adjusted
No.
Rate per
No. 10,000 per
annum
Porirua
Wellington
New Zealand
Preventable hospitalisations
Rate pe r
10,000 per
annum
Raw
No.
Case-mix-adjusted
Rate per
10,000 per
annum
No.
Rate per
10,000 per
annum
3,282
147
2,916
139
606
32
900
48
20,553
117
18,236
105
4,385
26
6,145
41
211,554
117
202,538
112
44,353
25
76,145
42
Source: Porirua Kapiti Healthlinks Project 2000b; based on data supplied by the NZ Health Information Service
Notes: Time period covers 1 January 1994 to 31 December 1998. Case-mix-adjusted discharges are based on
National AN-DRG, version 3.1, price weights. Standardised discharge rates reflect the average number of
discharges per annum over the 5-year period. Rates are calculated using 1996 Census night populations, and
use the New Zealand population as the standard. Direct standardisation is used throughout.
Not all materia l gathered from community and provider discussions was able to be
included, but the aim of this participatory research was to reflect the different views held
by the many participants.
The draft report was circulated within the
community and feedback incorporated to the final Report and Plan. The process is
regarded as ongoing and it is reported that the community looks forward to
implementation of the plan.
Recommendations are made in the areas of health partnerships, equity and fairness
(including population-based funding), health promotion and public health services, primary
care services, Mori health, Pacific health, maternity, child and youth health, older
peoples health, dental health, pharmaceutical services, specialist medical and surgical
services, disability support services and mental health services.
Recommendations have been discussed and agreed with the organisations involved and
in those cases are presented as action agreed. An example from intersectoral action
on health is shown in table 11.
55
Table 11:
Actions agreed
Action agreed
Performance measure (what by when)
Community directs the agenda

Capital Coast Health as a general
principle will involve local community and

voluntary providers, and key community
representatives in reviewing services and
in planning service changes.
Regional Public Health of Hutt Valley
Health will offer public health advice and

research support to community groups
where the community projects fit with their
strategic priorities.
Regional Public Health of Hutt Valley
Regular service reviews include local
providers and community members in the

review team.
Service planning teams include local
providers and community members in the

planning group.
Epidemiology and research advice for
small projects 50 hours/year.

Advice and support for about two larger
projects 50 hours/year.
First annual report in Decem ber 2001.
Health will provide the community with an

annual report to the level of Porirua City, on
public health issues, surveillance data and
their significance.
Source: Porirua Kapiti Healthlinks Project 2000b
Other recommendations presented for consideration by the Minister of Health were

categorised according to actions recommended. An example of this is shown in Table 12.
Evident from the report is the fact that the Healthlinks Project has been well supported
by Porirua City Council and its community. Implementation however, will be more
dependent on the views of the funder regarding this Health Action Zone. At 194 pages,
the report is required reading for DHBs. Again, it should be noted that this Report and
Plan does not set out to prioritise in any major way.
56
Table 12:
Actions recommended
Action recommended
What benefits will these

achieve?
Estimated
magnitude of costs
Suggested
priority
Intersectoral action to improve

health
It is recommended that:
Ministry of Health and the
funder support representatives of

Mori (tangata whenua and
taurahere), Pacific and other
communities in Porirua (Porirua
City Council) to advise DHB on
strategies to address health
disparities, and facilitate health
sector integration as well as
intersectoral action on the
determinants of health.
Greater impact on
health determinants.
Programmes more
effective.
Support for
intersectoral
programmes,
involving government,
local authority, iwi
and community to
address the
determinants of
health.
Central government agencies
work with the Porirua community

to address housing issues for
people with disabilities, including
providing funding for hostel
accommodation with personal
care and home support.
$50,000$100,000
Costs are based on
costs necessary to
supplement existing
community
infrastructure.
Improving housing
$ tens of thousands
for a small number of

people with
disabilities.
Source: Porirua Kapiti Healthlinks Project 2000b
4.2 Renal disease

Beech et al (1997) describe an example of an epidemiologically-based approach to
health needs assessment. This study, conducted in the context of the National Health
Service, addressed critical questions in commissioning services for patients with renal
disease. The main emphasis was on purchasing services for patients for end-stage rental
failure (ESRF). Services required for diagnosis and treatment of acute renal failure and
other renal diseases were also discussed. Renal replacement therapy (RRT) is very
effective in treating patients with ESRF, who would otherwise die within three to six
months. The majority of patients achieve an acceptable quality of life, but complex
treatment has to be given regularly and the overall cost is high, for what is a relatively
small number of people. The renal disease needs assessment considers purchasing
options for districts, by describing what is currently known about the epidemiology of
renal disease, the need for renal services, and the
57
effectiveness and cost-effectiveness of these services. Further areas for research are
identified.
The report begins with a statement and context of the problem (renal diseases without
failure, renal failure, acute renal failure, chronic renal failure, ESRF) and identifies
the associated ICD9 codes. Various subcategories are identified. Prevalence and
incidence are reported for each of the conditions and are related to the ICD9 data for
discharges per 10,000 population. Rates of acceptance on to RRT are noted from the
European Dialysis and Transplant Association Register. Age-specific incidence rates
for ESRF are noted, together with ethnic rates of RRT.
Services available for prevention, diagnoses and treatment of renal disease across a
range of settings are noted by disease entity. The number of new patients accepted for
RRT is recorded by region for the UK, alongside dialysis units, stock of patients accepted
for RRT and modalities by which they are maintained prior to transplantation. The
annual cost to the National Health Service of maintaining a patient on RRT is also
described (hospital haemodialysis, home dialysis, CAPD, kidney transplant operation and
maintenance).
The effectiveness of services for chronic renal failure is described in terms of
preventive actions that physicians could take to manage predisposing diseases
(for example, hypertension, diabetes, urinary tract infection, urinary obstruction and
acute renal failure). The effectiveness of services for diagnosing and treating renal
disease was reviewed, including survival rates following transplantation.
With
regard to cost-effectiveness of treatment of ESRF, RRT is expensive relative to
other health interventions.
Cost-effectiveness comparisons are
determined by cost per life-year gained, allowing comparison of data from various
treatment therapies. In all, the studies indicate that the main methods in order of costeffectiveness are:
successful transplantation
CAPD (home haemodialysis depending on case-mix and circumstances)
home haemodialysis
hospital haemodialysis.
Modelling of population need was done using the London Implementation Groups Report
on Renal Services to construct a flow diagram to anticipate future need in the steady
state. This had implications for the future configuration of services, particularly
transplantation. Prioritisations, outcomes and targets for transplantation and funding of
organ donation were determined. Recommendations for monitoring and evaluation of
renal services, alongside the future research agenda, were proposed. This
epidemiological review of renal disease, particularly regarding ESRF, models the
requirements for future renal services on an evidence base. This particular
epidemiological review forms part of a set of epidemiological reviews conducted in the UK
and published together, and is referred to in the bibliography of readings.
58
4.3 Economics, public health and health care

purchasing: the Tayside experience of
programme budgeting and marginal
analysis
This section describes an example of programme budgeting and marginal analysis
and reports the Tayside experience (Ruta et al 1996). The exercise was conducted to
consider purchasing priorities in child health in Tayside for 10 years, commencing in
1996. It was decided that a PBMA approach would be taken in order to release
resources from various programmes and make new investments in child health, consistent
with national policies. In Tayside, a small working group was formed to oversee the
project, consisting of a consultant in public health medicine, area nurse, medical advisor
and assistant director of finance. Over a six-month period a strategy was developed
that clearly identified priorities for purchasing in child health. This is now described.
Policy documents on the provision of child health services were reviewed, including
national policy documents published by government and professional bodies, local policy
statements and strategies produced by the Health Board and Regional Council. The main
outcome of the review of policy documents was to establish a very clear set of goals for
the pattern of provision of child health services up to the year 2005. These are summarised
in Box 7.
Box 7:
Goals for the pattern of provision of child health services in Tayside by 2005
Overall aim:
To maximise quality and length of life for children in Tayside by ensuring effective,
cost-effective, and equitable use of resources for child health services.
Goals:
To move towards primary care as the principal focus for health and health care for
children at Tayside.
To increase the proportion of child health care directed towards prevention and
health promotion.
To care for children outside hospital whenever possible and to minimise the length
of any hospital stays that are unavoidable.
To ensure a child- and family-centred service with children, siblings and their
parents or carers experiencing a seamless web of care, treatment and support,
as they move through the constituent parts of the NHS and related local authority
services.
59
These goals will be achieved by pursuing the following objectives:
To shift from hospital-based secondary care to integrated or shared care between

hospital and primary care, with the emphasis on management by the primary care
team using clinical guidelines.
To increase provision of services by paediatric community nurses offering

specialist care in a primary care setting, particularly for patients with chronic
illness such as asthma and diabetes, and for children with physical and learning
disability.
To expand the range of services provided in the community by professions allied to

medicine.
To shift away from hospital inpatient care to day-case surgery, outpatient care,
day care and hospital at home care.
To move towards an increasingly specialised secondary care hospital and

community service.
To commission jointly a range of integrated services which meet both health and
social care needs of children in Tayside.
4.3.1 Traditional methods of needs assessment

Epidemiological methods of needs assessment were used to compose a health profile
for children in Tayside. Epidemiological and demographic information was collated
for the children, with 10-year population projections. Health and social services activity
data (for example, hospital admissions, outpatient attendances, children registered with a
disability) provided valuable proxy indicators of morbidity. The findings revealed that
four conditions asthma, tonsillitis, limb fractures and otitis media accounted for almost
40 percent of the total admissions for children under the age of 15.
The majority of health care for children was found to be provided in the community,
with 260,000280,000 general practitioner consultations occurring per annum for
children in the 014 years age group. Respiratory, ear, nose and throat and
gastrointestinal consultations accounted for 64 percent of all consultations.
4.3.2 Programme budget matrix

A programme budget matrix was formed, with settings broadly categorised into
secondary/ tertiary and primary care, and then further subdivided. Programmes are
listed across the top of the page; data on expenditure and activity were obtained from
data sets within the Health Board contract management system, which included both
financial and hospital discharge information. This data was entered into a table and gives
a pattern of expenditure within the child health strategy programme matrix (see Table 13).
As can be anticipated, a number of estimations needed to be made:
60
A pilot study in two general practices was used to determine that 30 percent of
GP consultations were with children, and it was assumed that expenditure on
children would also approximate to 30 percent of the budget.
Data was accessed from the Tayside Medicines Monitoring Unit to identify
that 5 percent of the pharmaceutical budget related to children.
Consultations with GPs were shown to relate to children in 30 percent of cases.
Similarly, children use 20 percent of ophthalmic services.
Local NHS providers provided information regarding community services expenditure

related to community child health and community nursing services.
The programme budget helped to define a very disparate service. The very process
of designing and constructing the programme budget raised issues about possible
ways of changing service provision for children. It was noted that the disadvantage, at
this stage, was the time taken to construct the programme budget.
61
Table 13:
Programme budget matrix for the Child Health Strategy in Tayside
Expenditure (000)
General
paediatrics
Surgical
paediatrics
Special
care baby
Child
psychiatry
Mental
handicap
Community
paediatrics
Dental
Ophthalmology
Health
Other
Secondary and
tertiary care
Total
63
In-patient
ExpenditureActivity
38883779
24972707
4452491
5295747
2338600
38711
26389
327269
00
58138
131170
00
95627494
1010247
121868
00
33309622
107348
833
00
6915521
Out-patient
ExpenditureActivity
898Pop.
(71,943)
Day-case/day-patient
ExpenditureActivity
626
137581
00
4334533
Primary care
Practitioner
servicesExpenditureActivit
y
6011Pop.
(71,943)
904Pop.
(71,943)
3510Pop.
(71,943)
2594Pop.
(71,943)
671Pop.
(71,943)
262Pop. (71,943)
00
10,687Pop.
(71,943)
Services provided
by community
trustsExpenditureActivit
y
711630
1312103
00
34673733
Pharmaceutical
servicesExpenditureAc
tivityExpenditureActivity
1613Pop.
(71,943)
00
0000
00
00
00
31639035
2338600
7851910
00
00
00
00
250Pop. 025
years
1613Po
p.
(71,94
2500
Total ExpenditureActivity
11,9636296
8276725
4396Pop.
(71,943)
5356733
5221071
2500
00
29,60026,37
Source: Ruta et al 1996, p.188

Note: Community paediatrics includes child health surveillance/immunisation/screening.
64
4.3.3 The views of professionals

The views of health professionals in Tayside were obtained through a two-stage
process. Firstly, a multi-professional advisory group was formed with representation
from general practice, community paediatrics, child psychiatry, clinical
psychology, hospital and community nursing, physiotherapy and social work. This
group was given the remit to suggest areas for service development with substantial
potential for health gain and to identify areas where the reduction or reorganisation of a
service might release resources for reinvestment, with a net result of achieving greater
health gain for the resources spent. Group members were provided with a summary of
the policy review, the results of the need assessment and the programme budget matrix.
Each member was asked to suggest up to 10 areas for service development and 10
areas for reorganisation; they were asked to specify the nature of any proposed change,
and to justify their choice in terms of health gain.
The second stage involved a postal survey of health professionals working with children.
Respondents were asked to consider the epidemiological information, programme
budget matrix and again to choose 10 areas for new investment and 10 areas for
service redevelopment. Questionnaires and information packs were sent to 262
professionals across Tayside and a 50 percent response rate was obtained. Table 14
shows the top 10 areas suggested for service development in each case.
Table 14:
Top 10 suggested areas for service development and resource release, ranked
by frequency of mention
Rank
Service development
area
Score
Rank
Resource release ar ea
Score
Children with special needs
866
School health services
1323
Community liaison nurses
702
Health visitors
568
Respite care
653
Child development centre
527
Child protection
456
Child protection
459
Physiotherapy
421
Respite care
433
Services for adolescents
416
Dundee Royal Infirmary, Ninewells
419
Day patient care
404
Hospital bed numbers
412
Health visitors
274
Immunisation (routine)
346
Child development centre
268
Management
323
10
School health service
222
10
Developmental screening
320
A more detailed analysis of the suggestions showed that, while some of the most
frequently mentioned service areas were suggested as candidates for both investment
and resource release, it was certain aspects of a service that were consistently being
suggested for development while other aspects were suggested for resource release.
65
4.3.4 The views of parents

The views of parents as consumers were regarded as important, and to identify those
views two approaches were taken. First, a small in-depth focus group of parents of
children with different health problems was established. Second, a free-phone telephone
line was set up for a 24-day period with advertisements in the local paper inviting
parents to contact the telephone line. The group found that there were almost identical
views regarding unmet needs from both sources.
4.3.5 Review of research evidence on effectiveness and

cost-effectiveness
A literature review was undertaken in four service areas (treatment of otitis media,
respite care, role of the health visitor, and role of the school nurse). These areas were
selected because they were identified as possible candidates for service development or
resource release by parents and providers, although there was some disagreement among
providers over their perceived cost-effectiveness. Evidence was obtained for the best
approaches to managing these services.
4.3.6 Priorities for purchasing in child health

The child health strategy working group met to review all the available information
and survey findings. Priorities for service development were selected on the basis that
they represented the best potential for purchasing health gain for the children of
Tayside. Likewise, priority areas for resource release were identified on the basis that
releasing resources from these areas would result in little or no loss of health
benefit.
The
recommendations are summarised in Box 8.
66
Box 8:
Priorities for purchasing in child health in Tayside: main recommendations to the

Health Board with examples of specific changes identified
Priorities for service development/investment:
Children with special needs eg, development of one-stop-shop centre for children
with special needs; input from nursing, medical, physiotherapy, occupational
therapy, psychology, social work and education staff.
Community/liaison nursing service eg, community-based clinical nurse specialist

in asthma.
Community service for professions allied to medicine eg, physiotherapists for work
at home, school and elsewhere.
Respite care eg, residential respite care for holiday relief.
Improve quality of care in hospital eg, training in communication skills.
School health service eg, co-ordinated health promotion service, with school nurse
as key worker.
Health promotion eg, promote baby friendly hospital initiative.
Child protection eg, designated community paediatrician in child protection.
Services for adolescents eg, day patient programme for 1218-year-olds with
psychiatric problems.
Priorities for service reorganisation/resource release:
School health service eg, replace routine school medicals with selective
examinations.
Hospital admissions eg, increase day-case surgery for five commonest surgical
procedures.
Health visitor service eg, alter skill-mix.
4.3.7 Outcome of the child health strategy

The strategy was approved by the Health Board following public consultations and an
area-wide child health forum, including representation from the main National Health
Service child health professionals, trust providers and the Health Board. It was agreed
that the strategy would be implemented. The observation was made that the
recommendations won general support from local clinicians, even though high priority
was given to investment in non-medical, low-technology services in the non-acute sector.
It was felt that this reflected the strength of consensus that emerged from different data
sources, particularly from the survey of professionals. It was felt that the strategic
approach taken to priority setting, using the PBMA approach, resulted in a pattern of
provision of health care giving a more rational and efficient allocation of scarce
resources.
67
4.4 Rapid appraisal in an urban setting: an

example from the developed world
The following is an example of a rapid appraisal approach to health needs assessment
(Ong et al 1991). Consistent with the objectives set out by Annett and Rifkin (1988),
the South Sefton project took place in Bootle, one of the most deprived wards of the
District in the north-west of England. The population of 11,902 comprised 5720 males
and 6182 females. The majority of the housing in the district is council owned and a
considerable proportion is in need of repair. Because of a high level of
unemployment in the area (estimated at 20 percent), there is considerable male outmigration. The percentage of known one-parent families in the area is 6percent, of
whom the majority have children under five. Existing evidence of services used, both
from health and social services data, indicates that the ward suffers from multiple
deprivation.
Researchers within the District Health Authority brought together a research team with
the necessary skills to evaluate the area. Researcher backgrounds included community
nursing services, mental health, health promotion, operational planning, clinical
psychology, research and development, and from other agencies with a background in
housing, family practice, social services and research in social services.
The research team met together at a two-day workshop to determine the objectives of
the study (to define health and social needs of the South Sefton District using the rapid
appraisal approach), and following the information pyramid structure (see Figure 3) to
prepare the interview schedules for the project.
There was discussion on how to select the key informants in the community to ensure
that the views obtained were representative and that data saturation was reached.
Key
informants were people who had knowledge of the community because of their profession
(for example, social workers, health visitors or police). Within the community,
leaders emerged: self-help groups, voluntary associations or other political groupings (for
example, play group leaders, chairpersons of elderly groups or councillors). The third
category of informants were people who were centrally placed because of their work or
social role within the community. A list of names of people representing all three
categories was drawn up. The rationale behind including three distinct sources of
information was grounded in the social science approach of triangulation, which allows
the researcher to look at one issue from various perspectives, and then compare and
contrast these in order to reach an inter-subjective account.
The research team was divided into three sub-teams, each containing a representative
from the various agencies involved with the research, in order to allow a multisectoral
perspective in the interviews. Each team was allocated a group of people to
interview and the interviews took place over an eight-week period. Interviews were done
by appointment and the sub-teams visited participants in their own home or in their
workplace.
Additional information was obtained as background material, either to confirm
trends revealed in the qualitative analysis or to query the findings in terms of direction or
depth.
68
Analysis of the interviews was carried out following the formatic approach, filling in
the building blocks of the planning pyramid. Each sub-team had identified various
themes in a pre-analysis.
When the three sub-teams came together these themes
were discussed through comparing and contrasting, and intersubjective agreement was
obtained on the key issues that had emerged from the community. The subsequent
listing of priority problems was as follows:
physical environment: rubbish, poor housing, air pollution, disposal of syringes, lack
of recreational space
disease and disability: depression and anxiety, drug abuse, chest problems, poor diet
health services: lack of prevention services for children, too busy GPs, lack
of home-care support, lack of well women services, lack of chiropody
social services: information on social services not readily available, lack of preschool facilities, fear of the power of social services (to take children away), home
helps not free of charge
socioeconomic environment: unemployment, debts, unsafe environment
valuable resources: strong family support, community action groups. Bootle

identity, councillors, support from churches, Community Health Council.
Each item was placed on an index card and the categories were kept together. Team
members returned to the community to ask people to place the items in priority order. In
the process, the research teams learnt more about the main concerns in the community, but
the key informants also came to understand the limitations of statutory services, and the
need to prioritise problems. Before talking to the community about priorities, the team
first ranked the items themselves, in order to provide a comparison of their opinions
against those of the community.
The team also tried to rank on the basis of
what they understood the community felt to be priorities. The three sets of rankings
were analysed separately to assess the extent of agreement among the judges by
utilising Kendalls Coefficient of Concordance. As expected, there was considerable
difference between professionals and community.
The results show that despite intensive dialogue between community and professionals,
the understanding of professionals was mediated by their disciplinary and organisational
world view. The research team agreed, however, that the communitys word could not
be taken as gospel, that there were issues that needed further debate, and that the
communitys prioritisations could not always be taken at face value.
All participants in the project received a short paper reporting back on priorities
described from the research. Following distribution of the paper, a meeting was held with
participants and any other interested members of the community.
The priorities set by the community were taken as a point of departure and each was
discussed in-depth with the view to formulating action. This is the crucial part of
rapid appraisal, because so many projects stop at the point of diagnosis. It was
considered important to build on the communitys capacity, and on the collaboration that
had started in the research phase. To ensure that local planning, community involvement
and continuing evaluation of the contribution of services was taken into account, this
phase was essential
69
and required careful management by those involved. A crucial consideration was

the communitys need to be aware of the structure and decision-making process of the
local council, in order to understand what actions could be taken by the community itself
and what would be required by the Council, within the available resources.
The outcome was that steps were taken to implement the priorities of the community
with ongoing meetings to assess progress.
Rapid Appraisal aims to understand the strength of feeling in a community
through identifying priority problems. It tries to translate those priorities
into action by making a strong link between the community and planners
(resource holders) who are capable of instigating organisational changes
which will harness community capacity (Ong et al 1991).
70
Chapter 5: New Zealand Context

and Experiences
5.1 New Zealand Public Health and Disability
Act 2000
The New Zealand Public Health and Disability Act 2000 has the following purpose:
3
Purpose
The purpose of this Act is to provide for the public funding and
provision of personal health services, public health services, and
disability support services, and to establish new publicly-owned
health and disability organisations, in order to pursue the following
objectives:
(a)
to achieve for New Zealanders

(i)
the improvement, promotion, and protection of their

health
(ii)
the promotion of the inclusion and participation in

society and independence of people with disabilities
(iii)
the best care or support for those in need of services
It should be particularly noted that the aims of the Act should be achieved to the extent
that they can be reasonably achieved within the amount of funding provided. Implicit
in this statement is that some form of prioritisation will be necessary.
The clauses referring to functions of the DHBs as specified in the Act provide
information regarding the requirement for health needs assessment:
23
Functions of DHBs
(1)
For the purpose of pursuing its objectives, each DHB has the
following functions:
...
(g)
to regularly investigate, assess, and monitor the health

status of its resident population, any factors that the
DHB believes may adversely affect the health status of
the population, and the needs of that population for
services
...
71
(k)
to provide information to the Minister for the purposes

of policy development, planning, and monitoring in
relation to the performance of the DHB and to the
health and disability support needs of New Zealanders:
Clause 18(g) provides for DHBs to assess the need for services and 18(k) provides
that DHBs shall provide information to the Minister regarding the health and disability
support needs of New Zealanders.
In clause 38 the requirement for health needs assessment is again stated:
38
District strategic plans
(3)
Before a DHB determines or makes a significant amendment

to a district strategic plan, it must
(a)
assess the health status of that population, any factors

that the DHB believes may adversely affect the health
status of that population, the needs of that population
for services, and the contributions that those services
are intended to make towards the health outcomes and
health status sought for that population ...
Subsection 38(3)(b) refers to the requirement for DHBs to consult on district strategic plans.
(3)
Before a DHB determines or makes a significant amendment

to a district strategic plan, it must
...
(b)
prepare a draft plan or amendment and consult its

resident population on that draft.
The importance of a community voice is made clear in the Purpose of the Act.
3
Purpose
...
(c)
provide a community voice in matters relating to personal

health services, public health services, and disability support
services
District Health Boards will receive advice from community and public health
improvement advisory committees regarding the health needs of the resident population:
2
Functions of community and public health improvement advisory

committees
(1)
72
The functions of the community and public health

improvement advisory committee of the board of a DHB are to
give the board advice on
(2)
(3)
(a)
the needs and any factors that the committee believes

may adversely affect the health status of the resident
population of the DHB; and
(b)
priorities for use of the health funding provided.
The aim of a community and public health improvement

advisory committees advice must be to ensure that the
following maximise the overall health gain for the population
the committee serves:
(a)
all service interventions the DHB has provided or

funded or could provide or fund for the care of that
population:
(b)
all policies the DHB has adopted or could adopt for the
care of that population.
A community and public health improvement advisory

committees advice may not be inconsistent with the New
Zealand health strategy (Schedule 4 p.112).
In summary, the new Act requires a DHB, with respect to its resident population to:
conduct health needs assessments
consult on material aspects of the strategic plan
prioritise (implicitly) so as to achieve the purposes of the Act within the amount
of funding provided
assess the contribution that services are intended to make towards health
outcomes and health status.
This provides the legislative framework for health needs assessment, as described
in Chapter 3.
5.2 The New Zealand Health Strategy

In December 2000 the Hon. Annette King published the New Zealand Health
Strategy (Minister of Health 2000d). It gives a set of important principles to guide
the future development of the health sector:
Acknowledging the special relationship between Mori and the

Crown under the Treaty of Waitangi
Good health and wellbeing for all New Zealanders throughout their
lives
An improvement in heath status of those currently disadvantaged
Collaborative health promotion and disease and injury prevention

by all sectors
73
Timely and equitable access for all New Zealanders to a

comprehensive range of health and disability services, regardless
of ability to pay
A high-performing system in which people have confidence
Active involvement of consumers and communities at all levels

(p.vii).
The paper gives a number of goals and objectives to guide action on improving the health
of the community, and reducing differences in health status between population groups.
There are 10 goals (high-level strategic statements), which will be part of all the
goals and objectives. Each of the goals contains a number of objectives which contribute
to achieving a goal. Out of a total of nine goals and 61 objectives the Government
has highlighted 13 objectives for the Ministry of Health and DHBs to focus on for
immediate action:
reducing smoking
improving nutrition
reducing obesity
increasing the level of physical activity
reducing the rate of suicides and suicide attempts
minimising harm caused by alcohol, illicit and other drug use to individuals and
the community
reducing the incidence and impact of cancer
reducing the incidence and impact of cardiovascular disease
reducing the incidence and impact of diabetes
improving oral health
reducing violence in interpersonal relationships, families, schools and communities
improving the health status of people with severe mental illness
ensuring access to appropriate child health care services including well child
and family health care and immunisation.
The Government seeks to reconfigure the health and disability sector to improve the
overall health of New Zealanders. Government also proposes improving access to
public health services, primary health care services, public hospital services and mental
health services in the short to medium term. It states that The introduction of District
Health Boards will help to ensure that the servic es reflect the needs of individuals and
communities at a local level (p.3). District Health Boards will be responsible for the
health of their populations.
The changes will:
focus on population needs
reduce disparities in health
emphasise community and consumer involvement at all levels
74
improve co-ordination across the health sector so that the whole

system works for people ...
(Minister of Health 2000d).

The section on fundamental principles, goals and objectives to address social inequalities
in health considers sector-wide approaches to improving population health and to
reducing health disparities for Mori, with goals and objectives for each goal (pp.7-12).
It is clear from the various objectives contained within the document that an
assessment of health need has occurred on the basis of expert opinion using an
epidemiological evidence-based approach.
This needs assessment is a framework
for thinking about health needs assessment and priorities. The approach that DHBs
should take to the New Zealand Health Strategy has been discussed in the earlier chapters
on health needs assessment.
In addition to the New Zealand Health Strategy, the New Zealand Disability
Strategy discussion document was released in September 2000. The Strategy will:
create a vision and cohesive framework for disability to guide policy and
service development, including:
establishing goals for government activity in disability
identifying the major barriers faced by people with disabilities to

participation in society and achieving their full potential
identifying priority areas to remove these barriers
establishing targets to measure achievements of the goals
establishing mechanisms to regularly measure progress against

these targets
identifying a work programme (Health Funding Authority 2000e, p.7).
The implications for DHBs needs assessments are that they will need to take account
of priority goals, objectives, targets and performance indicators contained within the
New Zealand Health Strategy and the New Zealand Disability Strategy. Specifically,
Funding Agreements are expected to include performance measures for DHBs related to
the above.
5.3 Placing health needs assessment policy

into action
The following list details the operational steps for the process that will need to be
followed by DHBs.
1.
DHB defines health needs assessment programme objectives.
2.
DHB conducts health needs assessments in district, with involvement of Mori;

consultation with the public for prioritisation (function of Health
Improvement Advisory Committee).
75
3.
DHB reviews the health needs assessment (including prioritisation) and agrees
to fund/purchase to a certain level.
4.
DHB prepares strategic plan, annual plan and consults with community.
5.
Strategic and annual plans are approved by the Minister of Health.
6.
Annual plan is resourced through Vote: Health and the Funding Agreement with
the Crown.
7.
DHB implements health services according to the annual plan.
8.
Evaluation of effectiveness of health services delivery against annual plan

and performance measures contained within Funding Agreement.
Figure 7 demonstrates the policy context of health needs assessment.

Figure 7:
Health needs assessment rationale (policy)
Governments New Zealand Health Strategy and New Zealand Disability Strategy
These strategies will provide the overarching policy framework within which the health and disability sector will
be expected to operate. These strategies will establish specific nation-wide health and disability outcome
goals, objectives and targets, and sector performance standards.
Health needs assessment objectives
To obtain greater community involvement within the health and disability sector
consult communities on a broad front
To deliver outputs (including needs analysis)
To
Strategic plans
Community consultation and an environmental analysis of health needs in the community will
provide the basis for development of the plan.
Annual plan
The Annual plan will clearly and separately set out the outputs and associated performance expectations to be
achieved across the performance dimensions, including needs analysis (statement of intent).
Annual report
To enable DHB performance to be measured, each DHB will be required to provide an
annual report against the DHBs statement of intent, to be tabled in Parliament.
The DHBs will be involved in a change management process as the annual plans are put
in place. The relationship between health needs assessment, strategies, negotiation
of expected outcomes, strategic goals and targets is illustrated in Figure 8.
76
Figure 8:
Health needs assessment and change
Targets
Strategy
Broad context
Community health
needs assessmen Rational for
prioritisation
intervention
Change mechanism
Purposeful
investment in
activities, and
implementation
Negotiation of
expected
consequences and
practical outcomes
Outcomes
Strategic
goals
Source: Judge 2000

Note: Adapted for health needs assessment from Figure: Realistic evaluation and theories of change.
Policy settings are now in place for DHBs to prepare for health needs assessments in
their localities. One additional requirement is that DHBs should collate health needs
assessments that have previously been conducted in their locality. Work that has
already been done should not be duplicated.
5.4 The Treaty of Waitangi

The Treaty of Waitangi is regarded as the founding document of New Zealand. The
Treaty, signed in 1840, is the agreement between Mori and the Crown. It consists of
three articles, and is translated into both Mori and English versions.
Many of the difficulties in regard to the interpretation of the Treaty have arisen not
only because of differences between the two versions, but also because the Treaty has not
been fully acknowledged until recent years.
In 1987 the Court of Appeal considered the principles of the Treaty of Waitangi in a
landmark case. This case is of some importance in view of the interpretation that it gives
to the Treaty and its significance for all New Zealanders. The judgement is considered
here because of the importance of the Treaty not only in respect to land, but also in
respect to health because of its recognition of health as a taonga.
It would be widely agreed that the leading New Zealand judicial decision
on the subject of Principles of the Treaty of Waitangi is the 1987 Court
of Appeal of New Zealand Mori Council v Attorney-General, (1987) 1
NZLR p.641 (Jansen 1988).
77
The Court of Appeal considered the subject for decision (related to the return of land
to Mori) to be so important that all five judges gave separate judgements.
The Court
president, Sir Robin Cooke, gave the first judgement. This has been extensively quoted,
and used as an authoritative statement of the law.
The details of the case are that in 1986 the Waitangi Tribunal, in response to the
introduction of the State-Owned Enterprises Bill into the House of Representatives on
30 September 1986, made an interim report on a series of claims by the five most
northerly Mori tribes. The report expressed concerns that Crown land transferred to
such enterprises as the Forestry Corporation and the Land Corporation would cease to
be Crown land and so the Crown would have no power to return that land and waters to
Mori in accordance with a Tribunal recommendation. The Tribunal raised the question
of whether the Bill itself was contrary to the principles of the Treaty of Waitangi, at least
without some amendment that continued the responsibility of the Crown for the return of
land. As a result, the Bill was amended, with Section 9 providing that nothing in the Act
should permit the Crown to act in a manner that was inconsistent with the principles of the
Treaty of Waitangi. The Court of Appeal was asked to give a ruling on the interpretation
of the law.
To quote Sir Robin Cooke, Court President, on the principles of the Treaty:
The phrase the principles of the Treaty of Waitangi is beginning to come
into common use in New Zealand statutes ... The Mori Affairs Bill at
present before Parliament has recitals in the Mori and English
languages which may be seen as referring to some of the principles:
Whereas the Treaty of Waitangi symbolises the special relationship
between the Mori people and the Crown: And whereas it is desirable
that the spirit of exchange of sovereignty for the protection of
rangatiratanga in the context of this Act means the custody and care of
matters significant to the cultural identity of the Mori people of New
Zealand in trust for future generations; And whereas, in particular, it is
desirable the special relationship of Mori people to their land and for
that reason to promote the retention of that land in the hands of the
owners descent groups, and to facilitate the occupation and utilisation of
that land for the benefit of the owners descent groups: And whereas it is
desirable to establish agencies to assist the Mori people to achieve the
implementation of these principles.
... The principles of the Treaty are to be applied not the literal words. As
is well known, the English and Mori texts in the first schedule to the
Treaty of Waitangi Act 1975 are not translations the one of the other and
do not necessarily convey precisely the same meaning. The story of the
drafting of the Treaty and the procurement of signatures from more than
500 Mori chiefs, including some Mori women of appropriate rank
events in which no lawyer seems to have played a part is an absorbing
one, but not within the ambit of this judgement.
... Instead of repeating the two texts scheduled to the 1975 Act, I set out
what a distinguished Mori scholar, Professor Kawharu, calls his
attempt at a reconstruction of the literal translation of the Mori text
78
[Kawharu 1995]. It was put before us on behalf of the applicants. The

Crown likewise accepted it for the purposes of this case.
... Points on which that version may be open to debate include the
followingTaonga, rendered in the foregoing version as treasures, is
represented in the English text as other properties and in Williams (Mori
Dictionary) as property, anything highly prized ... The provision in the
third article to the effect that, in the words of the attempted
reconstruction, the Queen will give the ordinary people of New Zealand
the same rights and duties of citizenship as the people of England is
commonly rendered as referring to the rights and privileges of British
subjects.
The differences between the texts and the shades of meaning do not
matter for the purposes of this case. What matters is the spirit. This
approach accords with the oral character of Mori tradition and culture.
In this context the issue becomes what steps should be taken by the
Crown, as a partner acting towards the Mori partner with the utmost
good faith which is the characteristic obligation of partnership, to ensure
that the powers in the State-Owned Enterprises Act are not used
inconsistently with the principles of the Treaty.
... It will be seen that approaching the case independently we have all
reached two major conclusions. First that the principles of the Treaty of
Waitangi override everything else in the State-Owned Enterprises Act.
Second that those principles require the Pakeha and Mori Treaty
partners to act towards each other reasonably and with the utmost good
faith.
I have quoted extensively from this judgement by Sir Robin Cooke, Court president, firstly
in view of the importance of the Treaty as a founding document for New Zealand;
but secondly, in view of the relevance of the Treaty to health as a taonga. Further, as
will be seen later, land has a spiritual value and importance to Mori and therefore has an
impact on spiritual health and the health of the whole person.
5.5 The Treaty of Waitangi from a social

perspective
Use is made in this section of the excellent description of the Treaty of Waitangi,
its meaning and implications by Crengle (1997).
In 1988 the Royal Commission on Social Policy described Treaty principles which guide
the application of the Treaty to contemporary New Zealand (Durie 1994). To
understand the Mori perspective on health and health need for Mori, it is important to
understand the expectations that follow from the Treaty of Waitangi.
There are differences between the English and Mori versions of the Treaty. Mason
Durie states that in the English version, Article One established Crown sovereignty,
Article Two
79
conferred tribal property rights and Article Three guaranteed royal protection and
citizenship rights for Mori. In the Mori version, Article One established the authority of
the Crown to govern, Article Two allowed tribal authority over cultural, social and
economic resources, and Article Three guaranteed Mori a fair share of societys
benefits (Durie 1994). Instructions from the British Colonial Office to Busby linked
economic and social objectives and promoted policies of positive protection, a burden on
the Crown to ensure that Mori were not unfairly marginalised by British settlement and
that their well-being was ensured (Durie 1994).
The English version of Article Two provided confirmation of existing property rights and
a guarantee that property would not be unjustly alienated. The Mori version, in
translating sovereignty in Article One uses the word kawanatanga, a transliteration of
governorship. This is not to be taken as the equivalent of ceding sovereignty. The use of
the terms tino rangatiratanga and taonga katoa in the Mori version mean firstly,
full, exclusive and undisturbed use of the land, and in the second, effectively extended
the meaning to include cultural as well as material properties (Orange 1987; Durie 1994).
Both English and Mori versions of Article Three guaranteed Mori all rights and
privileges of British subjects. Implicit in this undertaking was the notion that there would
be no major gaps between Mori and other New Zealanders, with the obligation being on
the Crown to exercise royal protection should such discrepancies arise (Durie 1994).
The implications are that unequal needs will be treated unequally, with equal needs treated
equally.
5.6 The significance of the Treaty of Waitangi

for the health of Mori
The significance of the Treaty of Waitangi to health is tied to the meaning of health as
a taonga or treasure. Pomare and De Boer (1988) discuss the implications of the Treaty
in general terms:
Many Mori believe the Treaty articulates their status as tangata whenua
(indigenous people); guarantees their rights with respect to land, water,
forests, fisheries and treasures; and confirms their rights to Mana
Motuhake (self determination). The signing of the Treaty by both Mori
and Pakeha was seen as a recognition of a partnership of equals and the
basis for relationships between the two races implicit within the Treaty
were concepts of equity, partnership, and economic and cultural security,
all of which contributed importantly to hauora (spirit of life/health). Poor
standards of Mori health may therefore be regarded in part as nonfulfilment of these Treaty concepts and obligations.
Mori believe that health is a taonga and that the use of taonga katoa in Article
Two entitles Mori health to specific protection. This view was initially not supported
by the Crown (Department of Health 1992) which stated:
the claim that the protection of the health of Mori has (through Article 2)
a special claim on all New Zealanders as a whole, over and above the
80
responsibility of the Crown to secure the health of all citizens is, however,
not one the Government accepts.
However the responsibilities of the Crown in respect to Mori health are clearer in
Article Three. In respect to this article, Crengle (1997) states:
Equity of health status is guaranteed by the endowment of citizenship
rights and the obligation of the Crown to exercise royal protection
should any discrepancies between Mori and non-Mori arise.
In 1994 the Ministry of Health took a different position and acknowledged the Crowns
obligation to improve the Mori health status so that in future Mori will have
the opportunity to enjoy the same level of health as non-Mori (Ministry of Health 1994c).
It is generally agreed that Article Three covers the obligations of the Crown towards
Mori health and that Article Two may have additional implications for Mori health.
Despite the acknowledgement by the Crown that Article Three places special obligations
on the Crown in respect to the health of Mori, no reference to the Treaty has appeared in
any health legislation, including the Health and Disability Services Act 1993, until the
present time. However, since 1986 there has been an ongoing recognition of the need to
consider all legislation in the light of the Treaty of Waitangi, consult with Mori on
significant issues, and assess the resource and financial implications arising from any
Treaty considerations (Durie 1994).
In 1988 the Royal Commission on Social Policy described three principles that are
of particular importance to health and other social policies (Durie 1994):
Partnership: an on-going relationship between the Crown or its

agencies and Iwi. Iwi may be organised in a variety of ways (for
example, as trust boards, incorporated societies, runanga) and
there may be more than one representative body within a single Iwi.
Participation: meaningful, positive Mori involvement in all aspects

of New Zealand society. This can be at both the individual and
group level; and can involve both decision-making and service
delivery.
Active protection: the Crown is to adopt a proactive approach to

ensure that Mori well-being is enhanced wherever possible. In
health, active protection is largely about health promotion and
preventive strategies.
There is now full acceptance by Government, Ministry of Health, HFA and Mori, and
also (but not entirely) within the community that the principles of the Treaty of Waitangi
apply to issues of health and health service provision. The majority of health service
providers would now accept that view personally, even aside from the fact that the
application of Treaty policies within the health sector is enshrined by Treaty statements
in provider contracts. This is particularly important when one considers the rights and
entitlements of Mori to have the same level of health and also access to health services as
non-Mori.
81
In the context of health needs and services, Article Two relates to partnership rights and
Article Three to participation rights. It is interesting to reflect on the World Health
Organizations (1991) interpretation of participation, which they define as three sets
of activity.
A contribution by people to their own health and health care
The development of organisational structures that are needed for

participation to be effective
Empowerment of patients and their organisations and advocates, so

that their voice is heard not assumed.
This means that participation includes contribution, development of organisational

structures, effectiveness, empowerment and non-assumption that voices have been heard.
5.7 Health needs assessment and Mori

It is widely acknowledged that there are significant gaps in health outcomes between
Mori and non-Mori. This is simplistically represented in Figure 9.
Figure 9:
The gap in health outcomes between Mori and non-Mori
While some Mori enjoy the same level of health as non-Mori, many do not. Disparities
in Mori health relates to Mori health need, and the entitlement of Mori to equality in
health, ie, health outcomes/status. In the past this right to health has been equated to
equal access to health services, but current thinking goes beyond this to equality of
health outcomes for Mori and non-Mori.
There are four components to this equality:
equality of inputs in relationship to need
equality of access opportunity (theoretical)
82
equality of access utilisation (revealed)
equality of outcomes in relationship to need.
The Treaty of Waitangi in Article 3 provides for equal rights for Mori with nonMori, widely interpreted as including the right to good health.
It should also be borne in mind that Mori perspectives of health are considered to
be different from those of non-Mori. The most frequently cited is Te Whare Tapa Wha
(the four-sided house) incorporating four health components: taha hinengaro
(emotions and mind), taha wairua (spirituality), taha tinana (body) and taha whnau
(extended family) (Durie 1994). These dimensions in the wider context frame Mori
health need. This is useful to bear in mind when considering health needs assessments
for Mori. It does, of course, have implications for health (as opposed to health care)
need assessment, which is beyond the scope of the DHB process.
In summary, there are significant disparities in health status between Mori and nonMori, and not only does Treaty Article 3 provide Mori with the right to equality
(including health), but the New Zealand Health Strategy specifically provides that Mori
health outcomes will be addressed and health inequalities eliminated.
This has implications for health needs assessments, and health care and resource allocation.
Health needs assessments will need to:
acknowledge the objective of addressing the health disparities between Mori

and non-Mori
recognise that the goal is equality of health status for Mori and non-Mori
assess current Mori health-service delivery
define the gaps between Mori and non-Mori health status
consider Mori health need in terms of Mori models of health
prioritise recognising the existing eight Mori health-gain priority areas
consider the implications for health care delivery
consult with Mori.
In addition to the way health services are to be developed in the future, there
are implications regarding quantum. DHBs will need to consider distributional issues
arising from health needs assessment prioritisation. There will be implications for
health care delivery (unequal needs will be treated unequally, meaning additional resource
allocation to meet Mori health disparities). While under the Health and Disability Support
Services Act 1993, the Regional Health Authorities and HFA were required to address
disparities in Mori health, the New Zealand Public Health and Disability Act and the
New Zealand Health Strategy are explicit in this regard, with implications for need
assessment including prioritisation and consultation with Mori, and resource allocation. It
follows that those with greater health needs, such as Mori, will need greater health
resources invested in them.
83
5.8 New Zealand experiences with health

needs assessment
5.8.1 Area Health Boards
From all accounts, the old Area Health Boards did not directly engage in health
needs assessment.
They did, however, conduct pre-assessment exercises,
gathering epidemiological and health care service data related to their areas (for example,
Department of Health 1993am).
5.8.2 Core Services Committee

Few health authorities know what values the public holds regarding health
problems. However the Oregon exercise (Oregon Health Services Commission 1991;
Dixon and Welch 1991; Kitzhaber 1993), in which the public were involved in deciding
what services should be publicly funded and accessible for the poor via
Medicaid, has given encouragement to governments, health authorities and others to
obtain views from the public on what services should be prioritised and publicly funded
(NHS Management Executive 1992; Ham 1993; Murray et al 1994). In New Zealand,
this task was given to the newly established Core Services Committee in March 1992.
The Core Services Committee was required by its terms of reference to advise
the Government on what health and disability support services the Government should
purchase so that people could access effective services on fair terms. In effect, the
Committee was given the task of conducting a single, national health needs assessment.
The task consisted of:
reporting on the then current health and disability support services
identifying broad priorities for health and disability support services by means of
public consultation and submissions
establishing guidelines for the public to improve the effectiveness, health

outcomes and equity of access to some specific areas of service.
In essence, the task consisted of data collection, needs analysis and prioritisation, all
of which are components of health needs analysis. The approach of the Core
Services Committee in priority setting has been described in Chapter 4.
A significant shift in the Committees approach to prioritisation became evident in their
third annual report:
The Committee considers that advice on the kinds and relative priorities
of publicly funded services will best be achieved by a description of key
services in terms of the circumstances when they will be publicly funded
including their terms of access and quality standards (National Advisory
Committee on Core Health and Disability Support Services 1994).
84
The Committee reported on the specific work under way and completed to develop
advice on services that benefit people and the circumstances in which people should have
access to publicly funded services. It also reported on work developing evidence on the
balance and appropriate mix of services and levels of funding for those services.
Among its
recommendations were four key principles for use by Regional Health Authorities
with regard to purchasing decisions for core services for the1995/96 period. The
requirements were that:
the treatment or service provides benefit
the treatment or service is value for money
the treatment or service is a fair use of public funding
the treatment or service is consistent with the communities values.
In considering the question Is it value for money? the Core Services Committee
defined value for money as cost-effectiveness.
This requires information about
cost and effectiveness. Fundamental to effective assessment of health needs is
recognition of the bounds on what can be reasonably expected to be publicly funded where
there is a limitation on resources. The principles are relevant to health needs assessments
in general. DHBs could usefully consider them.
Guidelines
The Core Services Committee were unable to define a core of services to which the
public would have access. The Committee did not think it appropriate or workable to
strictly recommend the content, quality and terms of access to every single service.
Instead the Committee recommend(s) those people most directly involved adopt,
adapt, or develop transparent statements on the circumstances in which people can
reasonably expect access to the services. They also recommended that guidelines be in
keeping with the philosophy, principles and values that have already been
established and recommended by the Committee (National Advisory Committee on
Core Health and Disability Support Services 1995). In effect, a guidelines approach
replaced the core approach.
The core services exercise had major limitations, and was unable to proceed. It
was effectively discarded in favour of guideline development. It is a precedent of
failure for explicit health needs assessment and priority-setting.
5.8.3 Regional Health Authorities (RHAs)

The RHAs were actively involved in health needs assessment. They adopted the four
principles recommended by the National Health Committee (benefit, value for money,
fair use of public funding, consistent with communities values) to the processes of
needs assessment and prioritisation. The various health needs assessment exercises
conducted by the RHAs are listed in Appendix 5. The number of publications by the
RHAs indicates a considerable step-up in needs assessment activity, ranging from
epidemiological data collection, to consultation with communities and prioritisation of
services. Health needs assessments were also conducted internally to evaluate services
and cost-effectiveness of services.
85
5.8.4 Health Funding Authority

Appendix 5 shows evidence of activity by the HFA. Needs assessment was a routine
activity across personal health, public health, mental health, Mori health and
disability support services (including access to individual services in the latter case). The
prioritisation process, and the progress to reach that point, has been described in Chapter
4. Suffice to say, the HFA achieved a workable health needs assessment process, but
one that requires ongoing development.
5.8.5 District Health Board health needs assessment in

New Zealand
Health needs assessments for DHBs in New Zealand provides the opportunity for:
describing the health care needs of the population covered by the DHB,
being geographically defined by several local authority boundaries, and the
differences between district, regional and national populations
obtaining data from primary health care regarding enrolled (affiliated) populations
learning about the broad health needs and priorities of communities

through community consultation
highlighting the areas of unmet needs, ascertaining whether there are health
sector responses that are effective, and prioritising these within the health needs
assessment exercise
deciding rationally how to prioritise the use of resources to maximise health gain,
and distribution of health gain, to improve the health of the included population in
the most effective and efficient way
influencing policy, inter-agency collaboration and co-ordination, as well as

promoting evaluation, research and development priorities.
5.8.6 Summary
In reviewing the New Zealand experiences it is worth noting that health needs
assessment has been difficult to do. There have been difficulties with the definition of
need, and historically health authorities have not managed to make much progress in this
area.
86
Chapter 6: Best Practice In Health

Needs Assessment
6.1 Introduction
Best practice in health needs assessment means taking an evidence-based approach to the
policy, methods, conduct and implementation of health needs assessment exercises.
The evidence for these approaches is mostly contained within the literature referred to
in this paper. This chapter summarises the key points, which are grouped according to:
approach, methodologies and content
structural support
implementation.
6.2 Approach, methods and content

6.2.1 Stakeholders
The importance of bringing together a widely representative group of stakeholders for
health needs assessment exercises cannot be underestimated (Batterham and Jordan
1997). Such people play an important role in bringing credibility to the exercise, giving
considered opinion regarding the direction of a project (while not necessarily having the
power to determine that direction), providing multiple perspectives, locating previous
work done, and validating the needs identified. In addition they will be helpful in
enabling consensus regarding prioritising criteria. If changes are to result from needs
assessment exercises, then involvement of stakeholders from the outset is vital (Jordan
and Wright 1997).
Mori (and Pacific peoples) should be represented on stakeholder groups. Not only
does this assist partnerships in terms of Treaty obligations (Article 2), but it also
facilitates participation (Article 3). Separately, Mori need to be consulted in the
various stages of data collection, needs analysis, prioritisation, strategic planning and
implementation.
6.2.2 Objectives
The objectives of any health needs assessment should be clearly defined, so
find solutions to the questions What is the problem? and Why are we doing
The answers will help to resolve most of the uncertainty regarding health
assessments. Obviously, there are a number of other questions to be asked, and
together with the
as to
this?
needs
these,
87
importance of establishing the objectives, are stated in section 3.3. Health needs
assessments should not unnecessarily repeat existing work.
6.2.3 Approach and methods

Five approaches have been described in sections 2.4 to 2.8. Clarity of approach or a mix
of approaches is necessary to determine the method to be used in order to meet the
objectives. The methods should be appropriate for the approach.
6.2.4 Engagement with Mori

This has been well discussed and reference should be made to sections 5.4 to 5.6,
regarding partnership, consultation and equity for Mori.
6.2.5 Prioritisation
The importance of prioritisation as an integral component of health needs assessment
has been repeatedly emphasised. For a discussion on prioritisation, refer to Chapter 4.
6.3 Structural support

6.3.1 Resources
Projects may fail because of a lack of time, resources, or commitment (Wright et al 1998).
However, this can be managed by organisational commitment to the project, supply
of necessary resources, and a requirement to complete the task. Less time and resources
are required when the task is shared out among interested groups, with each contributing
their portion of information. As surveys cost both time and money it is important to
ensure that the information being sought is not available from other routine sources
(Williams and Wright 1998). It should be noted that the analyses are time consuming
and require skill to ensure that the data is correctly analysed to produce meaningful and
reliable information, given that prioritisation of services will be based on the health
needs assessment results. Allocating sufficient time for interpreting data and writing up
the report is essential.
DHBs may find that there are considerable advantages in shared support groups
across DHBs in a region providing support for health needs assessments. Boards
should work co-operatively to do health needs assessments on common topics. In
addition, they should develop a DHB-wide system for recording and making available
health needs assessment findings across New Zealand. This will reduce the need for
duplication within the sector. The new District Health Association may be the most
appropriate organisation to hold this data.
88
It will be important to ensure that an appropriate budget is developed for each health
need assessment. Under-funded projects will be compromised at some point during the
project, with the possible result that they will become meaningless exercises owing to lack
of robust data and best practice. Best practice does not equate to most expensive just
smartest. Information regarding the size of budgets required for health needs assessment
has been difficult to find.
6.3.2 Skill sets

It is important to ensure that there are sufficient and appropriate staff available to conduct a
needs assessment (Williams and Wright 1998). For effective health needs assessments,
the assessment and analysis team should consist of a range of researchers, including
an epidemiologist, public health physician, primary care physician, health economist,
medical sociologist and statistician, with representatives from clinical medicine, nursing,
management, social work, the voluntary sector and the community including patients.
The team should acknowledge these perspectives (McEwen et al 1995).
It is
important that the team members contain appropriately trained people, including
those with experience in the assessment of community needs using qualitative
methodologies. Differing agendas must be reconciled through real multi-disciplinary
working to produce effective collaboration.
6.3.3 Data
There are issues surrounding the use of local data only. Health needs assessments
conducted by DHBs are effectively locally based needs assessments. They have the
advantage of allowing locally collected data to be used not only to assess local need but
also to plan local services. However, the use of local data, to the exclusion of data
available elsewhere, needs to be carefully considered:
Apart from the cost implications of repeating locally what may have been
done perfectly well elsewhere and can be extrapolated, statistical
considerations need to be taken into account when assessing the
frequency of relatively rare events. Even diseases that are common
enough to be regarded as major public health problems ... occur
relatively infrequently in small populations (Williams and Wright 1998).
Sensible use of national data sets can also be considered. National findings may be
adapted to take into account how the local population differs. Another issue relates to
the local application of data collected nationally. Clearly, populations will differ in age,
sex, ethnicity and socioeconomic mix, and other attributes. There may be good reasons
for thinking that work carried out elsewhere (for example, nationally) does not have
validity for local use. However, it is important not to duplicate work done elsewhere if it is
applicable locally.
Issues of generalisability can be divided into four broad areas:
acceptability of case definitions
time duration since the study was carried out
89
soundness of the study with respect to methods of ascertainment (numerators) and

demographic information (denominators)
presentation of the data in relevant strata, bearing in mind known confounders

(used here to encompass attributes that influence incidence or prevalence, such as
age, sex, and socioeconomic or ethnic group) (Williams and Wright 1998).
6.4 Implementation
The importance of integrating the results of health needs assessment with planning
and purchasing intentions to ensure change has been emphasised earlier. Planning
for implementation should be an integral part of the whole exercise. Kilduff et al (1998)
draw attention to the importance of the team, context and organisation in which health
needs assessments are conducted. They found the main lesson was that focusing on
methodology of health needs assessments alone did not bring change unless there was
attention to the context within which it was being applied. The tool of health needs
assessment cannot be an answer or endpoint in itself. Conceptually, they suggest that
health needs assessment needs to be part of the developmental stage of the organisation
itself. They refer to a developmental spiral for organisations undertaking health needs
assessments as part of their activities. (This applies to DHBs, which will need to develop
organisationally in such a way that needs assessments is part of the integrated activity
that flows as part of the spiral development of the organisation.)
Five key loops in this spiral can be identified:
ensuring internal team consistency and appropriate organisation
maximising team potential for development
shifting from operational thinking to strategic thinking and practice
pursuing focused and owned health needs assessment
managing organisational and strategic change (Kilduff et al 1998).
6.5 Conclusion
There are a large number of dos and donts related to performing health
needs assessments. The sections above attempt to list some key points, but there are many
others contained within the body of this review. Attention to the points raised is more likely
to lead to successful health needs assessments, compared to those resulting from poor
planning leading to unsustainable conclusions.
90
Chapter 7: Concepts of Need

7.1 Introduction
This chapter considers the meaning of need, and the inter-relationships of need, demand
and supply. Concepts of need have been described from a diverse range of
perspectives, representing the views of sociologists, health economists, epidemiologists
and physicians (to name just a few). One perspective, which is often referred to, is
that of Bradshaw. He suggested the widely quoted definition of need as the capacity
to benefit (Bradshaw 1972). Bradshaw proposed a taxonomy of need, which highlights
four types of need. These can be broadly categorised in the following way:
normative needs (defined by experts)
expressed needs (needs expressed by action, for example, visiting a doctor)
comparative needs (comparing one group of people with another)
felt needs (those needs people say they have).
A normative need for health care arises where at least some expert assessors agree that
certain care ought to be provided. This assessment corresponds to what experts want for
the community. Experts are accountable to society for their assessments of community
need, and they should be guided by the best research evidence (of effectiveness)
available using epidemiological or biostatistical ways of thinking (Davidoff et al 1995).
Experts can also be informed by qualitative information, and by experience,
particularly where research evidence is incomplete, contradictory or not applicable to the
circumstance. Other influences will play a part when considering similar areas or social
groups through comparative need (Bradshaw 1972). Consideration of these
comparisons can inform experts considering issues of equity in assessment of need.
However experts alone cannot define needs. For needs to exist, the opinions of
experts must agree with those of community members and be consistent with rights that
society acknowledges.
Expressed needs signify requests for care. These may be spoken or expressed in gestures
(Metge and Kinlock 1984) or other action, such as attendance for care. Expressed needs
are typically referred to as demands (Wright et al 1998), frequently encountered
by providers. Demands may or may not be prioritised by those who are expressing
them. Where wants are not expressed, other people may infer them. Such inferences
should be verifiable with the original source of the want. The greater the likelihood that
values and goals vary between people, the greater the need to ask and verify assumptions.
Felt needs describe what people want or believe they need for themselves (Carpinter
1989; Liss 1993) or family members. Liss suggests that these wants differ from needs
because to want something implies some knowledge and desire of it, whereas these
conditions do not apply to need. In contrast, Buetow and Coster (2000) contend that
peoples capacity to make choices and have wants depends on how they value things
and on their knowledge
91
and desires. Under this interpretation, it is argued that people cannot need something
they do not want. The neediness of wants (or goals) further results from the potential for
harm resulting from failure to achieve them. Society should also assist people to have and
express informed wants, especially since some people are disadvantaged because the
needs they report are limited by their awareness of alternatives, low expectations,
modesty, deference, or lack of confidence (Carpinter 1989).
Considering need according to Bradshaws structure presupposes a social administrative
view suitable for such public sector services as housing and education. In such areas it
is much more difficult to determine with certainty capacity to benefit in contrast to
health care, where increasing inputs of care can be associated with not only life or death,
but also with zero benefit, or negative benefit (Stevens and Raftery 1994). In health,
increased inputs can be detrimental.
From another perspective, Buetow and Coster (2000) propose a theoretical framework
for the meaning of health need which is consistent with the New Zealand Health
Strategy. They claim that for individuals or groups to need health care, two sets of
criteria must hold. First, the care must avoid harm. Harm in this case is any interference
with activities undertaken to meet the goals of the population and its members. Second,
for individuals or groups to need care, (a) they must have a right to it, (b) they must
want it, and (c) some experts must believe they ought to be able to access it. All three
conditions must hold for needs to exist because each condition is a necessary but not
sufficient condition for need.
7.2 Need for health care

The underlying assumption of the following discussion is that need refers to the
capacity to benefit. Implicit within this definition is the concept that health status may
improve when specific services are provided to meet that need. Thus a patients
need for a specific therapeutic procedure is related to his or her potential to benefit
from it (Sanderson et al 1997). While Crampton and Laugesen (1995) acknowledge
some problems with defining need in this way, they adopt the definition because there
is no point in devoting resources to health care if there is little chance that people will
benefit. Similarly Stevens and Gabbay (1991) states there can be no rational need for
either an individual, or a population, to receive an item of care that confers no benefit.
Theoretically if needs are to be identified, then an effective intervention and appropriate
resources should be made available to meet those needs. The presence of one without
the other means that the capacity for benefit is stymied and therefore harm may result.
At this point a distinction should be made between the need for health and the need
for health care. While the need for health underlies the need for health care, it does
not completely determine the need for such care (Gillam and Murray 1996). The
need for health care is much more specific and is closely related to a populations
capacity to benefit from health care, and will be dependent on both morbidity and the
effectiveness of care. It is the need for health care that is relevant to this paper and is
fundamental to health care needs assessments (Stevens and Gabbay 1991).
Assessment of health care needs has become an integral part of health service
planning in health service reform over the past
decade.
92
For
examp
le, in
the
UK
health
authori
ties were required, following the 1991
reforms to assess the needs of their populations and purchase appropriate health care.
Such moves require a measurement of the populations health care need at a finer level
so that the question of who needs what services ie, the need for health care can be
answered (Stevens and Raftery 1994).
It is essential here to differentiate clearly between individual need and population need.
Clinicians focus on the individual, with need defined according to what can be done for
a particular patient at a particular time, with less consideration of cost of treatment. There
are practical differences between the clinicians view of an individuals capacity to
benefit and those of the population-based approach taken by epidemiologists and health
economists. The clinical view takes no account of those people with health care needs who
do not attend a clinician. In contrast, population need must also take account of the
people who do not present for care. Costs are viewed differently, as they must be
managed if the health of the population is to be maximised. Resources are finite, but in a
clinical setting, the limits are seldom perceived (Stevens and Raftery 1994). Tension
between what is best for the individual and what may be best for society will always
present a dilemma for clinicians (Gillam and Murray 1996).
The tension between individual need and population need is comparable to that existing
in between need, demand and supply. The integration of need with demand and supply
is a task that has been undertaken by health economists. However, while demand and
supply are concepts inherent to a market paradigm and basic to micro-economics, the
concept of need does not fit comfortably within such a framework. The balance
between supply of health care and demand has not equated with a populations need for
such care (Stevens and Raftery 1994; Wright J ed 1998).
7.3 Interpretation of need

Accepting need as the capacity to benefit from health care can be interpreted from a
range of perspectives, including those being cared for and those who care.
The resulting
interpretations will be coloured by an individuals sources of information. As Stevens
and Raftery (1994) suggest, a professionals understanding of benefits is likely to be
affected by not only clinical networks but also the recent research agenda.
Another factor influencing need is changes in what health problems exist at a
particular time. Recent developments that highlight this factor range from new initiatives
within the community for the care of psychiatric patients and the much greater role played
by women in their obstetric care. The interpretation of need can also depend on cultural
perspectives to health. In addition, various technological innovations have an impact
on health care needs and the likely benefits resulting from their implementation. The
interpretation of need is therefore, to a certain extent, contextual.
7.4 Demand
Demand can quite simply be defined as what the patient wants; in other words, the
health care people ask for. Thus demand is based on self-assessed wants. It is in fact what
health
93
care providers most commonly experience from people. Demand can therefore be
unlimited. Clearly at a primary care level GPs, in a sense, function as gate-keepers
in controlling demand (Wright J 1998). However, a simplistic explanation of demand belies
its complexity and the effect of other factors impinging on it. For example, the
availability of particular services may increase the demand for them. Conversely, the
unavailability of other services or difficulty of access may result in such services not even
being considered, thus reducing demand. One example is the existence of long waiting
lists, which tend to diminish enthusiasm for surgical procedures in the public hospital and
therefore encourage supply from the private sector.
Thus important factors that influence demand include geography of location,
demographics of the patient population, individual patient characteristics, characteristics of
a health service and health service providers, funding, as well as political and
media influences. Paradoxically, the greatest certainty about demand is its changing
nature (Stevens and Gabbay 1991). The ways demand is met give an indication of the
characteristics and the factors that influence supply.
7.5 Supply
According to Buetow and Coster (2000), society usually permits people to act on
different views of what needs are ... [though] most doctors will consider needs in
terms of health care services they can supply (Wright et al 1998). Underpinning this
supply perspective is a definition of need as a capacity to benefit, where benefit
depends on an effective intervention and available resources (Stevens and Gillam
1998; Crampton and Laugesen 1995). Supply being the provision of health care is
thus dependent on such factors as available resources, political will and
prioritisation, interests and availability of health providers and facilities (Stevens and
Raftery 1994; Wright J 1998). From the foregoing discussion it is evident that the
elements of need, demand and supply cannot be understood in isolation. Considering
their interrelationships is a prerequisite to assessment of health needs.
7.6 Need, demand and supply

The relationships between need, demand and supply are graphically illustrated by
Stevens and Gabbay (1994) in the figure below, which reveals the way these aspects are
not only intertwined but also separate. It shows eight fields of services divided into
(i) those for which there is a need but no demand and supply; (ii) those for which there is
a demand but no need for supply; (iii) those for which there is a supply but no need for
demand, and then (iv vii) the various degrees of overlap.
94
Figure 10:
Interrelationship between need, supply and demand

Cultural and ethical
determinants
Media
The current
research
agenda
NEED
4
DEMAND
2
Medical influence
7
6
Public and
political
pressure
SUPPLY
3
8*
Social and
educational
influence
Historical patterns,
inertia, momentum
Notes: Need = What people benefit from; Demand = What people ask for; Supply = What is provided;
* = The external field where a potential service is not needed, demanded or supplied.
According to Frankel et al (2000), perceived discrepancies between supply and demand

in health care are almost inevitably accounted for by commentators as rationing
(the curtailment of access to health care). The rationing debate from this point of
view is described as being far from scientific, and surrounded by literature which is
claimed to be dominated by assertion, political analysis and ethical debate.
While demand is greater than supply in many cases, it does not inevitably follow that
specific health care requirements can not be met. In fact Frankel (1991) advocates the
desirability of an empirical determination of health-care requirements. Such an
approach would require dispensing with the pessimism inherent in the commonly held
view that satisfying demand is destined to futility. Empirical evidence resulting from
such research may well reveal that there is no need to ration those interventions of
undoubted efficacy.
Frankel (2000) highlights the error of the widely held assumptions of an inevitable
mismatch between supply and demand. Using data from the UK relating to
conditions requiring surgical intervention, as in the cases of total hip replacement and
treatment cataracts, he observes that such a view has little or no epidemiological
support. In addition, common perceptions of the effects of factors such as increasing
life expectancy, new technologies and raised public expectations deemed responsible for
the continuing imbalance between supply and demand in the health-care environment are
shown to be inaccurate.
95
In conclusion Frankel et al (2000) claim that:

The demand for health-care must be finite: The population is finite and
only a proportion of the population can benefit from and want treatment
... The conventional null, or nihilist, hypothesis that demand always
exceeds supply within a public health system reflects neither hope nor
experience ... The limits to demand for key categories of health care lie
within the capacity of a properly resourced NHS.
96
Appendix 1: The Treaty of Waitangi

The following is a translation of the Mori version of the Treaty of Waitangi by
Professor Sir Hugh Kawharu (Kawharu 1995).
Victoria, the Queen of England, in her concern to protect the chiefs and
subtribes of New Zealand and in her desire to preserve their chieftainship
and their lands to them and to maintain peace and good order considers
it just to appoint an administrator one who will negotiate with the people
of New Zealand to the end that their chiefs will agree to the Queens
Government being established over all parts of this land and (adjoining)
islands and also because there are many of her subjects already living on
this land and others yet to come.
So the Queen desires to establish a government so that no evil will come
to Mori and European living in a state of lawlessness.
So the Queen has appointed me, William Hobson a captain in the Royal
Navy to be Governor for all parts of New Zealand (both those) shortly to
be received by the Queen and (those) to be received hereafter and
presents to the chiefs of the Confederation chiefs of the subtribes of New
Zealand and other chiefs these laws set out here.
The first
The Chiefs of the Confederation and all the chiefs who have not joined
that Confederation give absolutely to the Queen of England for ever the
complete government over their land.
The second
The Queen of England agrees to protect the chiefs, the subtribes and all
the people of New Zealand in the unqualified exercise of their
chieftainship over their lands, villages and all their treasures. But on the
other hand the Chiefs of the Confederation and all the Chiefs will sell
land to the Queen at a price agreed to by the person owning it and by the
person buying it (the latter being) appointed by the Queen as her
purchase agent.
The third
For this agreed arrangement therefore concerning the Government of the
Queen, the Queen of England will protect all the ordinary people of New
Zealand and will give them the same rights and duties of citizenship as the
people of England.
Signed William Hobson
Consul
and
Lieutenant
Governor
So we, the Chiefs of the Confederation and of the subtribes of New
Zealand meeting here at Waitangi having seen the shape of these words
which we accept and agree to record our names and marks thus.
97
Was done at Waitangi on the sixth of February in the year of our Lord
1840.
The
Chiefs
Confederation
98
of
the
Appendix 2: District Health Boards,

Populations and Geographical
Areas
Table A1:
District Health Boards, populations and geographical areas
DHB
Population
projection
2001
Geographical areas
(territorial authorities)
Northland
146,700
Far North District, Whangarei District, Kaipara District
Waitemata
445,500
North Shore City, Rodney District, Waitakere City
Auc kland
391,500
Auckland City
South Auckland
387,500
Manukau City, Papakura District, Franklin District
329,500
Hauraki District, ThamesCoromandel District, Waikato District, Waipa

District, Hamilton City, South Waikato District, MatamataPiako District,
Otorohanga District, Waitomo District, Ruapehu District (Ohura,
Taumarunui and National Park Wards only)
100,000
Taupo District, Rotorua District
182,800
Tauranga District, Western Bay of Plenty District, Whakatane District,

Kawerau District, Opotiki District
Waikato
Lakeland
Bay of Plenty
Gisborne District
Tairawhiti
46,300
Taranaki
104,000
New Plymouth District, Stratford District, South Taranaki District
Hawkes Bay
146,100
Wairoa District, Hastings District, South Taranaki District
Wanganui
66,300
Wanganui District, Rangitikei District, Ruapehu District (Waiouru

and Waimarino Wards only)
Manawatu
161,000
Manawatu District, Palmerston North City, Tararua District, Horowhenua

District, Kapiti Coast District (Otaki Ward only)
Hutt
134,800
Upper Hutt City, Lower Hutt City
250,600
Kapiti Coast District (Paraparaumu, Waikanae and Paekakariki

Raumati Wards only), Porirua City, Wellington City
Capital Coast
Wairarapa
Nelson Marlborough
West Coast
Canterbury
South Canterbury
Otago
Southland
38,000
122,600
32,300
440,000
53,300
176,000
104,500
99
Total
3,859,000
The populations within this table are projected to 30 June 2001. The information has
been supplied to the Health Funding Authority by Statistics New Zealand.
100
Appendix 3: Sources of Health

Information
Databases that can be accessed for epidemiological and other information are
clearly necessary, especially for epidemiological reviews.
The comparability and
therefore usefulness of various databases is dependent on the use of common data
definitions for disease, disease stage and severity. Findings from a study in the UK
confirm that the absence of common disease definitions, common classification
systems, compatible software, and the partial recording of activity, limits the value of
many databases (Pringle and Hobbs 1991). A good example of the type of data
available from primary care organisations can be found in the FirstHealth Value Audit
2000 (FirstHealth 2000).
Conclusions reached through health needs assessments are only as good as the data on
which they are based. High-quality needs assessments results require the use of highquality information. It follows that where poor quality or less reliable data is used,
attention should be drawn to that fact. Good-quality local data on health services
utilisation can be hard to obtain, but every effort should be made to do so. In every
circumstance the source of data should be referenced, and the method of data
collection recorded so that data reliability can be judged. Wherever possible data should
be triangulated (information from one source compared with information from other
sources to obtain an overall view of a subject area) to ensure that correct interpretations
are being reached.
A number of databases are available (Ministry of Health 1999c, d; Mori Health
Operating Group 1999a, b, c, d, e, f, g, h, i, j, k). The data from the above
references has been reworked by the HFA for DHB distric ts, and is available to project
managers on the HFA internet.
The New Zealand Health Information Service provides considerable health data (for
example, hospital discharge data (New Zealand Health Information Service
1999)). Additional information regarding laboratory and prescribing data is available
from Health Benefits Limited, a wholly owned subsidiary of the HFA responsible for
payment of health benefits to Hospital and Health Services (hospitals) and other nongovernmental providers, including GPs and providers of mental health services, Mori
providers and disability support services.
Primary care databases are available for general practice from Independent Practitioner
Associations, although the scale and quality of information varies widely. An analysis of
the quality of data supplied by the FirstHealth network of practices in the western Bay of
Plenty found that the quality of data recording was adequate for most statistical purposes
(Gribben et al 2000a). Databases of information surrounding the quality of care
need to be developed. The same authors have developed indicators to measure the
quality of care for population-based primary care in New Zealand (Gribben et al 2000b)
and these evidence-based quality indicators are generalised for use in monitoring primary
care.
101
Information regarding best practice is widely available from such sources as the
evidence-based medicine literature, Cochrane Library and the website of the New
Zealand Guideline Group of the Ministry of Health (www.moh.govt.nz).
Timely and accurate information about the health status of populations is necessary
for managers and health planners if they are to provide appropriate health services to
respond to the needs of their populations.
Care should be taken to ensure that
routine health information is accurate, complete and up to date (Wright and Walley 1998).
The following sources of health information are available in New Zealand. The table
below shows this information by type, information and reference source.
Table A2:
Sources of health information in New Zealand by type, information and reference

source
Type
Health information
Source
Population
Census data describing populations and

projections at national, regional and local
authority level by age, gender, ethnicity, and
socioeconomic status
Statistics New Zealand
Census data describing income levels, numbers

per household, cars, telephones
Socioeconomic deprivation data
NZDep 96 index (Salmond et al 1998)
Birth and ethnicity data
Plunket Society
Population projections
Prof. Ian Poole, University of Waikato,

National registration of deaths
National Register of Births, Deaths

and Marriages
National registration of cancer-related deaths
New Zealand Cancer Registry
HFA locality mortality data
HFA profiles (eg, Mori Health

Operating Group 1999a)
National mortality rates, risks and life

expectancy
Ministry of Health 1999c
National perinatal database
To be established
Injury-related data
Accident Compensation Corporation
Mortality
102
Type
Morbidity
Health care
Community
Health information
Source
National morbidity data, including patterns and

trends, burden of disease, injury patterns
New Zealand health survey including disease

burden, health status, injuries
Ministry of Health 1999d
HFA morbidity data
HFA profiles (eg, Mori Health

Operating Group 1999a)
National hospital discharge data
New Zealand Health Information

Service 1999
Injury-related data
Accident Compensation Corporation,

Health Funding Authority
Disability data
Ministry of Health 1999c, d
Mental health data
Mental Health Commission
Primary care morbidity and resource use
McAvoy et al 1994
Mori morbidity and resource use in general

practice
Davis et al 1997
Health service utilisation, including primary

health care and hospitalisation, prescription
item use
National workforce data
Medical Council of New Zealand,

Ministry of Health
Provider database
Ministry of Health
Existing service data (contracts)
Ministry of Health
National health survey data including health risk

behaviours, health service use, satisfaction
survey data, use of GP services, prescription
data, unmet health need
Primary care data including consultation data,

Read Code data, utilisation data
Primary care organisations, including

Independent Practitioner Associations
Community characteristics and data
Local authorities, community surveys,

key informant interviews and focus
groups
Some of the above information is available in disaggregated form, and where DHBs
consult sources of data they should ascertain if the form and availability is suitable for
the DHB requirements. In most cases the data is available without charge, but this
should be checked. In some cases, confidentiality of information may be an issue.
103
Appendix 4: Service and Treatment

Areas for Health Needs
Assessments Internationally
During the course of the literature review a number of papers or publications were
found that reported variously the methods and results of health needs assessments.
These are listed in Table A3.
There are several observations that can be made about these reports. Firstly, not many
health needs assessments have been published. Although it is evident from the
literature that health needs assessments have been conducted in the UK for at least the last
decade, it appears that many of those by District Health Authorities are held as
internal or local reports. This situation is mirrored in New Zealand, where some health
needs assessment exercises are held as internal papers within the HFA.
Secondly, health needs assessments have been conducted over a wide range of areas, with
a surprisingly high number of publications resulting from primary care/community
origins. This may reflect a publishing bias, with more complex assessments being
retained within health authorities, or that more activity has occurred in this area by nature
of the UK health system.
Thirdly, more often than not prioritisation has not been included as part of health
needs assessment. In those cases where more detailed analysis has been completed,
prioritisation is an integral component of the needs assessment.
The health needs assessments listed in the following table provide a useful
resource regarding approaches taken over a range of health service delivery areas.
104
Table A3:
Service and treatment areas for health needs assessments internationally

Title
Methodological issues in a team

approach to health needs assessment
Service area
Comment
Author and year
Community analysis
Community and health data sources

and key informant interviews by
Barton et al 1993
Patient satisfaction with health care
Patient satisfaction surveys to assess

health care need
Bowling 1992
Health service priorities in a health

authority
Focus groups to obtain public views

regarding health services, values and
prioritisation
Bowie et al 1995
Relevant to all health service

prioritisation
Questionnaire survey of public, hospital

consultants, public health physicians
and GPs regarding health service
priorities
Bowling et al 1993
Place effects for areas defined by

administrative boundaries
Community health needs assessment

Ontario Health Survey
Health survey health problems and

health-related quality of life, wellbeing
and family functioning
Boyle and Williams 1999
The health of their nation: how would

citizens develop Englands health
strategy?
Mental illness, coronary heart disease

and stroke, accidents, HIV/AIDS and
sexual health, cancers
Use of focus groups to develop health

strategy
Bradley et al 1999
Survey of the opinions of general

practitioners about health services in a
rural setting
Rural GPs surveyed to measure health

services need
Questionnaire survey to assess quality

and quantity of services in rural areas
Brockway and Jones 1993
Setting targets: A three-step model for

determining priorities for health promotion
Health promotion for women in Hunter

Region of New South Wales
Epidemiological data, community

survey and key informants (two
committees)
Brown and Redman 1995
Developing reliability in client-centred

mental health needs assessment
Mental health client needs
Bangor Assessment of Need Profile
Carter et al 1996
Assessing health needs and

measuring patient satisfaction
Consulting the public about health
service priorities
Health services priorities: exploration in

consultation of the public and health
professionals on priority setting in an inner
London health district
105
Title
Needs assessment and palliative care:
the views of providers
Service area
Needs assessment for palliative care
services, including hospices and
specialist palliative services
Comment
Survey of 203 in-patient hospice
services together with 12 qualitative indepth case studies
Patients evaluate their hospital care: a

national survey
Author and year

Clark et al 1997
Cleary et al 1991
Marginal analysis: an alternative to

health needs assessment for
contracting health care
Ten health gain areas (eg, maternal

and early child health)
Methodology for investment and

divestment in health service purchasing
Cohen 1994
Primary care needs assessment and

resourcing: complementary practice and
geographic perspectives
Primary care needs assessment

(97 practices, 380,000 people)
Demographic, socioeconomic,
prescribing and practice data, including
referrals
Congdon 1999
Community Responses to Changes in

Delivery of Rural Health Services in
Balclutha and Dannevirke
Rural hospital and health services
Key informant interviews, available

literature
Coster 1999
Priority settings: lessons from Oregon
714 condition-treatment pairs in Oregon
Priority setting using the costutility

method, public attitudes and values
Dixon and Welch 1991
An Audit of Value added to the New

Zealand Health Sector
Primary health care services
Extensive report on primary health care

data available from First Health
FirstHealth 2000
A Survey of Needs Assessment Activity

in London Health Authorities
General
Evaluation of health needs

assessments conducted by health
Fulop and Hensher 1997
Needs Assessment in General Practice
Wide variety
Authoritative publication, well referenced
Gillam and Murray 1996
COPC: A public health experiment in

primary care
Community-orientated primary care in

4 health authorities and 11 practices
Kings Fund COPC programme and

evaluation
Gillam and Miller 1997
106
Title
Service area
Comment
Author and year
Rapid assessment of health status and

preventative medicine needs of newly
arrived Kampuchean refugees, Sa Kaeo,
Thailand
Health status and preventive medicine

needs
Refugee population
Glass et al 1980
Patients priorities with respect to general

practice care: an international comparison
General practice services
International comparison of patient

needs, expectations and priorities in
general practice care
Grol et al 1999
Priority setting in the NHS: reports from six

districts
General
Commentary on findings
Ham 1993
Rapid health needs assessment following

Hurricane AndrewFlorida and Louisiana,
1992
Immediate health and social service

need
Household survey methodology
Hlady et al 1992
Socioeconomic circumstances, limiting

long-term illnesses, 14 ongoing health
problems, minor illnesses,
Postal survey of stratified random

sample
Hopton and Dlugolecka 1995a
Research design and methodology for a

local mental health needs assessment
Local mental health service needs
Use of surveys, focus groups, and

semi-structured interviews of provider
groups
Hostick 1995
Growing old in place: a view from rural

New Zealand
Rural health and social services in two

rural communities
Key informant interviews
Joseph and Chalmers 1995,

1999
Health needs assessment in primary

care: the evolution of a practical public
health approach
Primary care services in a Total

Purchasing Project (Lancashire)
Variety of approaches
Kilduff et al 1998
Prioritising health services in an era of

limits: the Oregon experience
All health services
Broad consensus by Health Services

Commission
Kitzhaber 1993
Health needs assessment in general

practice: the Cretan approach
Community-orientated projects in
primary health care in Greece
Used morbidity, mortality data and

primary care utilisation data
Lionis and Trell 1999
Need and demand for primary health

care: a comparative survey approach
107
Title
Local Health and the Vocal Communities:
A review of developing practice in
community-based health needs
assessment
Service area
Comment
Author and year
Primary and community care health

services
Needs-based approach at health

authority level; excellent resource
London Health Economics

Consortium 1996
Needs assessment at a practice level:

using routine data in a meaningful
way
General practice-based needs

assessment, to provide health and
social information
Practice-coded hospital activity

information and other epidemiological
information utilised for purpose
Mackenzie et al 1997
Monitoring and promoting equity in

primary and secondary care
All health services (eg, ischaemic heart

disease)
Routine data sources from primary and

secondary care used to assess needs
for care a framework and example
Majeed et al 1994
Interregional variations in measures of

health from the Health and Lifestyle Survey
and their relation with indicators of health
care need in England
All health services, self-assessed need,

and chronic disease
Use of Health and Lifestyle Survey data

vs routinely available need indicators as
measures of need for health care
Mays et al 1992
All current health services
Epidemiological review with community

consultation
McGrath 1999
Health and social needs in general

practice
Rapid appraisal methodology
Murray et al, 1994
Primary health services
Use of rapid participatory appraisal,

postal survey, analysis of routinely
Murray and Graham 1995
Health and social needs; also mental

health, alcohol and drugs
Rapid appraisal in central Edinburgh
Murray 1999
Health and Health Services for Porirua
Listening to local voices: adapting rapid

appraisal to assess health and social
needs in general practice
Practice-based health needs
assessment: use of four methods in a
small neighbourhood
Experiences with rapid appraisal in

primary care: involving the public in
assessing health needs, orientation
staff, and educating medical students
Community assessment in general
practice
Neve 1996
108
Title
Allocating resources in health care:
alternative approaches to measuring needs
in resource allocation formula in Ontario
Service area
All health services
Comment
Proxies of need using standardised
mortality ratios and socioeconomic-
Rapid appraisal in an urban setting: an

example from the developed world
Author and year

Newbold et al 1998
Ong et al 1991
Rapid appraisal of needs in

reproductive health care in southern
Sudan: qualitative study
Reproductive health care
Rapid appraisal with key informants, indepth interviews, group discussions,

and secondary care data
Palmer 1999
Is use of hospital services a proxy for

morbidity? A small area comparison of the
prevalence of arthritis, depression,
dyspepsia, obesity, and respiratory disease
with inpatient admission rate for these
disorders in England
Arthritis, depression, dyspepsia,

obesity, and respiratory disease in a
health district
Caution must be exercised when

hospital service use is being
considered as a proxy for morbidity in
health needs assessment
Payne et al 1994
Setting Priorities in South Australian

Community Health II: Marginal analysis of
mental health services
Mental health
Marginal analysis
Peacock et al 1997
FNQRDGP Community and Consumer

Needs Project
All health services in the Far North

Queensland Rural Division of General
Practice
Epidemiological data, mail survey of

GPs and communities; interviews of
providers and community groups, focus
Far North Queensland Rural

Division of General Practice
1997
Health Needs in Primary Care
Primary care services
Use of practice and external data, key

informant interviews and rapid
Pringle et al 1997
Ischaemic heart disease
Use of practice data
Pringle 1998
Preventing ischaemic heart disease in one

general practice: from one patient, through
clinical audit, needs assessment, and
commissioning into quality improvement
109
Title
Service area
Comment
Assessing the health needs for cancer

services for people from ethnic groups
Cancer services in ethnic groups
Factors and differences for

consideration
Determining the Priorities for Change in

Primary Care: The value of practicebased needs assessment
Primary care services
Use of practice data, postal survey,

morbidity statistics and nominal group
Limitations of epidemiologically-based
needs assessment: the case of
prostatectomy
Need for prostatectomy surgery
Expert panel to determine treatment

criteria, postal survey and multistate life
table
Can general practice data be used for

needs assessment and health care
planning in an inner-London district?
General practice
Community involvement in assessing

health needs of immigrant Salvadoreans
living in Washington
Health needs of immigrant

Salvadoreans living in Washington
Needs assessment in mental health

services: the DISC Framework
Rawaf 1996
Sanderson et al 1997
Scobie et al 1995
Focus group of community leaders and

community health need survey
Epidemiological assessment of the health

and nutrition of Ethiopian refugees in
emergency camps in Sudan
Allocating resources to health authorities:
results and policy implications of small
area analysis of use of inpatient services
Author and year
Shankar et al 1998
Shears et al 1985
Mental health
Use of inpatient facilities in NHS

hospitals
Smith et al 1994
Need for mental health services
Describes stakeholder approach using

a framework for assessing mental
Smith 1998
110
Title
Health care needs assessment: the
epidemiologically-based needs
assessment reviews
Service area
Comment
Author and year
Diabetes mellitus, renal disease,

stroke, lower respiratory disease,
coronary heart disease, colorectal
cancer, lung cancer, hip replacements,
Use of epidemiological and costeffectiveness of interventions data for

named health conditions in the NHS;
extensive
Stevens and Raftery 1994
Emotional health problems are the most

important cause of disability in adults of
working age: a study in the four counties of
the old Oxford region
Emotional health problems in people of

working age contributing to burden of
disability
Postal questionnaire survey of random

sample of population using SF-36
questions
Stewart-Brown and Layte 1997
The health service needs of small

communities
Rural health services
Focus groups of community members,

providers and administrators
Strasser et al 1994
The use of special surveys of health needs

of elderly populations as a basis for
establishing policies and plans
Elderly populations
Needs assessment surveys in the

elderly
Tapia-Videla 1985
Use of self-report postal questionnaires for

district-based adult oral health needs
assessment
Adult oral health needs in districts
Self-report postal questionnaires

administered to random samples of
older residents
Tickle et al 1996
A systematic review of the literature on

patient priorities for general practice care.
Part 1: description of the research domain
Patient priorities for general practice

care
Literature review and analysis of 57

studies, ranking of relative importance
of features
Wensing et al 1998a
General practice care and patients

priorities in Europe: an international
comparison
General practice servi ces
International comparison of patient

needs, expectations and priorities in
general practice care
Wensing et al 1998b
111
Title
Assessing the health needs of elderly
people
Service area
Comment
Author and year
Personal health needs assessment of

elderly in one practice
Needs assessment form and case

study reports
Whiteley and Brittain 1993
A pharmaceutical needs assessment in

a primary care setting
Unmet pharmaceutical needs of

community
Gap analysis, nominal group and rapid

appraisal techniques in patients of
medical centre
Williams et al 2000
Acknowledging the expertise of patients

and their organisations
Long-term medical conditions
Use of patient organisations to obtain

input re decision-making for their own
Wilson 1999
Tailoring health services to the needs of

individual communiti es
Resource requirements in Greater

Glasgow
Community profiling using

standardised mortality ratios,
socioeconomic indicators, hospital
Womersley and McCauley 1987
112
Appendix 5: Health Needs Assessments Conducted by the

Ministry of Health and the Health Funding Authority and
Predecessors over the Decade, 19912000
Title
A Review of Evidence: A background document to support Kia Piki
te Ora o te Taitamariki
Service area
Author and year
Background document to the Mori youth suicide

prevention strategy, epidemiological review of the
evidence
Aho 1998*
The health of Pacific Islands people in New Zealand
Health and population characteristics
Bathgate et al 1994*
A Review of Evidence in Our Hands: The New Zealand Youth

Suicide Prevention Strategy
Review of the epidemiological research evidence

behind the youth suicide prevention strategy
Beautrais 1998*
Adolescent Sexual Practices: A study of sexual experiences and

service needs among a group of New Zealand adolescents
Sexual practice, experiences and service needs in

adolescents
Brander 1991*
Women living with HIV/AIDS: Issues and needs confronting women

with HIV/AIDS
Needs of women with HIV/AIDS and those caring for

them
Brander and Norton 1993*
Lists needs assessments done in area before February

1993
Cathie and Gleisner 1993*
Needs assessment for alcohol and drug service

providers
Central Regional Health

Authority 1994a
Towards a Healthier Porirua-Kapiti
Health status, health promotion and community health

services for population

Authority 1995d
Towards a Healthier Hawkes Bay


Authority 1995c
Needs Assessment in the Auckland/Northland Region
Alcohol and Drug Services in the Central Regional Health Authority

Area: A report on service providers and referral sources
113
Title
Towards a Healthier Wellington
Service area
Author and year


Authority 1995e
Te Kete Tuputahi Whakakaokao Korero: Our first two years 1993

1995
Health service need and demand, including for Mori,

and health policy

Authority 1995b
Public Consultation on Changes to Consultation for 1996/97 in

Secondary and Tertiary Medical and Surgical Services, Maternity
Services, Public Health Services
Consumer participation in organisation and

administration of maternal health services

Authority 1995a
Poutama Whirinaki: Interwoven Paths: The report of the Central RHA

Wanganui Needs Assessment
Health services needs and demands, health status and

socioeconomic factors

Authority 1996
Strong Links: Building better services to meet the health and

disability support service needs of people in Porirua
Community health services organisation and

administration

Authority 1994c
Planning for Health: A summary of the health and disability support

services which Central Regional Health Authority plans to purchase
1994-97
Community health services organisation and

administration, health priorities and delivery of services

Authority 1994b
Health resource need of the Lakes region, access to

and availability of health services
Cheung and Health &

Disability Analysis Unit 1996
First Steps Towards an Integrated Maternity Services Framework: A

report
Maternal health services organisation and

administration
Coopers and Lybrand 1993*
Prophylactic Treatment for Severe Haemophilia A: An assessment of the

costs and benefits
An assessment of the costs and benefits
Coopers and Lybrand 1995*
Strategic Directions for the Mental Health Services for Pacific Island
People
Needs and directions for mental health services for

Pacific Island peoples
Crawley et al 1995*
Rural health service needs and demands, and planning

for rural communities
Creech 1999
Special health care needs of refugees
Deloitte Ross Tohmatsu

1991*
Report on Resource Equity for the People of the Lakes Sub-Region
Rural Health Policy: Meeting the needs of rural communities
An Investigation into the Special Health Care Needs of Refugees for the
Auckland Area Health Board
114
Title
Service area
Author and year
Assessment of Geographical Access to Primary Care Providers:

Area Health Board Report: data tables on Taranaki Area Health
Board
Primary care services on a geographical basis, and

local census data
Department of Health 1993k
Assessment of Geographical Access to Primary Care Providers: Area

Health Board Report: data tables on Otago Area Health Board

local census data
Department of Health 1993i

Health Board Report: data tables on Southland Area Health Board

local census data
Department of Health 1993j

Health Board Report: data tables on Wellington Area Health Board

local census data
Department of Health 1993m

Area Health Board Report: data tables on Waikato Area Health
Board

local census data
Department of Health 1993l

Health Board Report: data tables on Canterbury Area Health Board

local census data
Department of Health 1993h

Health Board Report: data tables on Nelson-Marlborough Area Health
Board

local census data
Department of Health 1993e

Area Health Board report: data tables on Northland Area Health
Board

local census data
Department of Health 1993f

Health Board report: data tables on Bay of Plenty Area Health Board

local census data
Department of Health 1993b

Health Board Report: data tables on West Coast Area Health Board

local census data
Department of Health 1993g
115
Title
Service area
Author and year

Health Board Report: data tables on Manawatu-Wanganui Area Health
Board

local census data
Department of Health 1993d

Area Health Board report: data tables on Auckland Area Health
Board

local census data
Department of Health 1993a

Health Board Report: data tables on Hawkes Bay Area Health Board

local census data
Department of Health 1993c
Health Care Needs Assessment Study: South Island West Coast
Health care needs assessment
Dunt 1999*
Progress with Mori health initiatives
Conference proceedings on progress with Mori health

targets and initiatives
Earp 1998
People with Disabilities on the West Coast and Their Needs
Health status, quality of life and needs of disabled

people
Fitzgerald and Fitzgerald

1992*
An Assessment of Health Needs for the Good Health Wanganui

Region: Phase 1
Health needs assessment, with demographic,

household, employment, socioeconomic and
epidemiological data, and key informant interviews
Good Health Wanganui 2000*
Assessment Project Report: A report summarising articles, processes,

tools and general information relati ng to the assessment of people with
disabilities, collected over a three month period from 11 January 1993
to 10 April 1993
Harris 1993*
The Review of Support Needs of People with Severe Head Injuries
Support needs of people with severe head injuries
Head Injury Working Group

1994*
The People of the Midland Health Region
Comprehensive analysis of the people of the region

population, families, education, occupation, income,
benefits
Health and Disability Analysis

Unit Midland Health 1994
Family Health Services in the Midland Region
Analysis of family health services detailed analysis

Unit Midland Health 1997a
116
Title
Service area
Author and year
The People of the Midland Health Region, Volume 2: Health status,

Part 1: Infants and children
Health status of infants and children in the Midland

region detailed analysis

Unit MIdland Health 1995
The People of the Midland Health Region, Volume 2: Health status,

Part 2: The health status of young people
Health status of young people in the Midland region

detailed analysis

Unit Midland Health 1996
Documents changes in population size and

composition, and comparative overview of subpopulations

Unit Midland Health 1998a
Sexual and reproductive health in the Midland region

detailed analysis

Unit Midland Health 1997b
Pregnancy and childbirth in the Midland region

detailed analysis

Unit Midland Health 1998b
Discussion Document on Psychiatric Needs Assessment and

Service Coordination in the Southern Region
Psychiatric needs assessment

1998a
DSS Funding Principles and Needs Assessment and Service Coordination
DSS needs assessment standards and co-ordination

consultation paper

1999a
Mori mental health

1999b
Child and youth mental health

2000b
Kapiti District Health and Disability Report and Plan
All health services
Porirua Kapiti Healthlinks

Project 2000a
Porirua District Health and Disability Report and Plan
All health services
Porirua Kapiti Healthlinks

Project 2000b
Diabetes 2000
Diabetes needs assessment nationally

2000a
The People of the Midland region II. Composition and Change
Sexual and Reproductive Health in the Midland Health Region,

Volume 2, Part 3
Pregnancy and Childbirth in the Midland Region
Kia Tu Kia Puawai
He Nuka mo nga Taitamariki: A national workplan for child and

youth mental health services
117
Title
Service area
Author and year
The Health of the People in the South: West Coast, Canterbury,

Otago, Southland
Epidemiology, health status, needs assessment data,

population characteristics and health services need

1998b
HHS Purchasing Project: Terms of reference and project charter:

needs analysis and volume purchase decisions
Needs analysis and volume purchase decisions

1998c
Improving Our Health in Wellington
Health status of people of the greater Wellington

population and publicly funded personal health services

2000c
An Assessment of Dental Needs for Low Income People
Dental needs assessment for low-income people
Healthcare Management
Associates 1995
Report to the Ministry of Health: Health profile of the Wellington

region
Examines patterns of mortality and hospitalisation in the

Wellington region
HealthSearch 1998
Socio-economic Inequalities in Health Care: A preliminary analysis of

the link between health status and socio-economic status in the North
Health region
Health status and socioeconomic factors
Jackson 1998
Deprivation in South Auckland: An analysis of deprivation in South

Auckland using NZDep96, including an examination of hospital
discharge data
Links socioeconomic deprivation to hospital discharge

data
Jackson 1999*
Assessing Sexual Health Education Needs in Young People: A

report for the Public Health Commission
Knowledge, attitudes, sexual practices, and educational

needs of adolescents
Kizito 1995
A Healthy Future: Report on Wairoa District health and disability

support services
Organisation and delivery of community health services,

disabled and health priorities
Lane 1994*
Need and Demand for Cardiac Surgical and Related Services in the
Central Region
Needs for cardiac surgery
Malcolm 1994*
Management Review of Tararua Health Services
Health needs of the people of the Tararua region, health

services, and plans
Manawatu-Wanganui Area
Health Board 1991
Profile of the Wellington Locality
Demographic profi le, epidemiology and health status of

people in the locality
Mori Health Operating Group

1999k
118
Title
Service area
Author and year
Profile of the Otago, Southland Locality
Demographic profile, epidemiology and health status of


1999f
Profile of the Canterbury, West Coast Locality


1999c
Profile of the Bay of Plenty Locality


1999b
Profile of the Northland Locality


1999e
Profile of the Waikato Locality


1999i
Profile of the Wanganui, Manawatu Locality


1999j
Profile of the Tairawhiti, Hawkes Bay Locality


1999g
Profile of the Nelson, Marlborough Locality


1999d
Profile of the Auckland Locality


1999a
Profile of the Taranaki Locality


1999h
Profile of the Wellington Locality, 1999
Demographic and epidemiological data for the people

of the Wellington region

1999k
Blueprint for Mental Health Services in New Zealand: How things

need to be
Blueprint for mental health service delivery
Mental Health Commission

1998
Evaluating the National Support Needs Assessment Protocol

Report on phase one
Evaluation of whether the support needs protocol

accurately assesses need for disabled people
Middleton and Brindson 1993
119
Title
Service area
Author and year
Evaluation of the National Support Needs Assessment Protocol
Evaluation of tool by survey of CHE assessors and

service co-ordinators
Middleton et al 1994
An Assessment of Dental Needs for Low Income People
Needs assessment for dental services with costing

estimate
Midlands Regional Health

Authority 1995
Future Directions for Health and Disability Support Services in the

South Waikato (including Tokoroa, Putaruru, Tirau and Mangakino)
Consultation document for health and disability

services, including forecasting, and for Mori health
needs
Midland Health 1996
Health and Disability Support Services in the Midland Health

Region: A discussion document: Thames, Coromandel, Hauraki

services, including Mori health needs
Midland Health 1994b
Health and Disability Support Services in the Midland Health

Region: A discussion document: Tairawhiti

services, including Mori health needs
Midland Health 1994a
New Zealand health needs assessment and strategy

discussion document
Minister of Health 2000d
Policy papers on health; includes health promotion,

delivery of services, and policy update
Ministry of Health 1999b
National immunisation strategy, health promoti on, and

planning for preventive health services
Strengthening Public Health Action: The strategic direction to

improve, promote and protect public health
Public health goals to meet identified need, expert

opinion and public/provider consultation
Ministry of Health 1996b, c,

1997d
National Drug Policy: A national drug policy for New Zealand 19982003
Substance abuse (tobacco, alcohol, drug), extent of

need, policy making
Making a Pacific Difference: Strategic initiatives for the health of

Pacific people in New Zealand
Ethnology and health need for Pacific peoples in New

Zealand
Our Childrens Health: Key findings on the health of New Zealand

children
Health needs of children
The New Zealand Health Strategy
Healthy Opportunities: Leading in health and disability: briefing for the

incoming Minister of Health 1999
National Immunisation Strategy 1995
120
Title
Service area
Author and year
Our Health Our Future: Hauora Pakari, Koiora Roa: The health of
New Zealanders, 1999
Mortality, morbidity, socioeconomic and health status

indicators for New Zealanders
Introduction to Needs Assessment for People with Disabilities
Needs assessment for people with disabilities
Strengthening Public Health Action: The strategic direction to

improve, promote and protect public health
Health planning, promotion and administration to

improve the public health
Purchasing for Your Health: A performance report on the Regional

Health Authorities
Health services needs and demands, accessibility and

standards
Your Rights and Responsibilities: Standards for needs assessment for

people with disabilities
Standards for needs assessment for people with

disability
Action for Health and Independence: Bridging the gap between

actions and outcomes ... the population perspectives
Community perspectives on population health needs,

service and outcomes
Ministry of Health 1998a
Strengthening Public Health Action: A review of a strategic direction to

improve and protect the public health: a discussion document
Health planning, organisation and administration to

improve the public health
Waiting Times Fund: Clinical priority assessment criteria
Clinical priority assessment criteria for access to

publicly funded services
Ministry of Health 1997e
Assessing the Support Needs of Older People
Social and health service support needs for older

people
Progress on Health Outcome Targets 1996
Epidemiological reports on progress towards health

outcome targets
A Better Way: Standards for needs assessment for people with

disabilities (video)

disabilities
Progress on Health Outcome Targets, Te Haere Whakamua ki nga

Whainga Hua Mo te Hauora
Epidemiological reports on progress towards health

outcome targets
Ministry of Health 1998e
National review of health status and health service

utilisation (extensive)
Taking the Pulse: The 1996/97 New Zealand Health Survey
121
Title
Service area
Author and year
Strategies for the Prevention and Control of Diabetes in New

Zealand
Needs, prevention and control of diabetes
Child Health Strategy
Health priorities and needs for children, including Mori
Strengthening Public Health Action: The background paper
Health status, planning, organisation and

administration to improve the public health
Standards for Needs Assessment for People with Disabilities

disability
Korero Pasifika: Consultation review making a Pacific difference
Community consultation workshop reports, health

status, consumer satisfaction, health planning and
promotion, ethnology
Facts about Disability Support Services (DSS) in New Zealand
Health delivery, services, economics, expenditures and

policy
Advance Womens Health: Kokiritia te Hauora Wahine: A checklist for

Regional Health Authorities and Crown Health Enterprises
Womens health services, supply and distribution
Ministry of Womens Affairs

1995
In our hands: New Zealand Youth Suicide Prevention Strategy
Epidemiology and prevention of youth suicide
Ministry of Youth Affairs 1998
Otara Community Primary and Public Health Needs Assessment
Community needs assessment
Mitchell 1995*
The Best of Health 2: How we decide on the health and disability

support services we value most
How we prioritise health and disability support services,

and cost-benefit analysis
National Advisory Committee

on Health and Disability
Support Services 1993a
Disability Support Services: Priorities
Disability support services and priorities a consensus

conference report
National Advisory Committee

on Core Health and Disability
Support Services 1993b
Review of Maternity Services in New Zealand
Review of needs, quality and standards of maternal

health services
National Health Committee

1999
Health care needs for older people, and organisation of

services
National Health Committee

2000
Report of the National Health Committee on Health Care for Older

People
122
Title
Service area
Author and year
Hauora Wahine Mori: A discussion document on Mori womens

health; Hauora Tane Mori: A discussion document on Mori mens
health
Epidemiological data and discussion on health issues

for Mori women and men
North Health 1996a
Pacific Island People: A demographic profile of Pacific Island people

living in the North Health Region
Demography and ethnography of Pacific people in the

Northern region
North Health 1995
Pacific Islands People in the North Health Region
Population characteristics of Pacific people in the North

Health region
North Health 1997
Locality Plan 1994/95: Auckland City and Gulf Islands
Locality planning for health and disability services

against need, and population requirements
North Health 1994a
Locality Plan 1994/95: South Auckland

North Health 1994c
Locality Plan 1994/95: West Auckland

North Health 1994d
The Health of Women: Strategies to improve the health of women
Womens health status, health promotion and

organisation of services
North Health 1996b
Socio-economic Inequalities in Health Care
Epidemiological analysis of health and socioeconomic

analysis
North Health 1998
Locality Plan 1994/95: North Shore and Rodney

North Health 1994b
Health and Disability Support in the Northern Region: Strategic

directions for 1994-97
Health and disability support services, consumer

participation and planning
Northern Regional Health

Authority 1994
Assessment of Health Needs in the Porirua Area Summary
Health needs assessment
NRB 1994*
Hospital Services for the Wellington Region: Submission to the

Ministry of Health
Hospital service needs for the Wellington region

results of needs assessment
Porirua City Council 1999a*
Submission to the Ministry of Healths The New Wellington Public

Hospital: Discussion Document
Hospital service needs for the Wellington region

results of needs assessment
Porirua City Council 1999c*
123
Title
A New Hospital for the Wellington Region at Kenepuru
Service area
Author and year
Needs assessment for hospita l services
Porirua City Council 1999b*
Maternity services need in Porirua
Porirua Community Health

Group and Porirua Health
Health Waikato Population Needs Assessment Part One: Population

projections
Population projections within the region
Portal Consulting &

Associates Ltd 1999a
Health Waikato Population Needs Assessment Part Three: Hospital

expectancies
Analysis of patterns of utilisation of publicly funded

hospitals in Waikato cf New Zealand
Portal Consulting &

Associates Ltd 1999c
Health Waikato Population Needs Assessment Part Four: In-patient

hospital use by the Health Waikato catchment population based on
service related groups, 1996-2011
Estimated and projected service patterns and service

mix of publicly funded hospital days in Waikato cf New
Zealand
Portal Consulting &

Associates Ltd 1999d
Population needs assessment of functional limitation

and implications for service provision
Portal Consulting &

Associates Ltd 1999b
Health status indicators for Mori, public health and

socioeconomic factors
Public Health Commission

1995b
A Strategic Direction to Improve and Protect the Public Health: The

Public Health Commissions advice to the Minister of Health 19931994
Health planning and promotion

1994
Our Health, Our Future: Hauora Pakari, Koiora Roa: The state of the
public health in New Zealand 1993
New Zealand epidemiological data major resource

1993
Ethnology, health status and socioeconomic factors for

Pacific peoples

1995a
Guidelines for the Use of the Support Needs Assessment Protocol for
Older People
Use of guidelines for age-related disability support

needs assessment
Regional Health Authority

1993
Care for Older People in New Zealand
Health needs of the elderly
Richmond 1995
Case Study: Maternity services and care in Porirua
Health Waikato Population Needs Assessment Part Two: People

with functional limitations in the Health Waikato Area 1996-2011
Whakapiki Mauri: Mori health advancement
The Health of Pacific Islands People in New Zealand: Summary
124
Title
Whangarei Area Health and Disability Support Services Needs
Assessment
Service area
Author and year
Epidemiological, health services and community

consultation regarding health need assessment in
Whangarei area
Scanlen 1995*
Piloting the Draft National Support Needs Assessment Protocol:

Results
Use of guidelines for age-related disability support

needs assessment
Scotney 1992*
Primary Mental Health Care: A discussion paper on current issues

and service provision
Community mental health service needs and demands
Simpson 1993*
Needs Assessment Pilot Project 1994
Health needs assessment for various chronic disease

groups, testing assessment standards
Southern Regional Health

Authority 1994
Residential Support Subsidy Assessment Tool: Physical disability
Subsidy assessment tool

Authority 1996
The Assessment and Management of People with Co-existing

Substance Use and Mental Health Disorders
Substance abuse and mental health needs

assessment

Authority 1999
Costing Needs Assessment and Case Management Services for

Midland Health June 1996
Costing needs assessment
Stacey 1996*
The People in the North Health Region: A demographic profile
Demography, ethnicity, and socioeconomic profiles
Walker 1995
* These reports from non-health authority sources were identified during the course of the research. However, they by no means represent the full extent of health needs
assessments by local authorities, or other bodies.
125
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Health Needs

Published in December 2000 by

Health Needs Assessment for New Zealand

Health Needs Assessment for New Zealand

Chapter 2: Health Care Needs Assessment

Context of health needs assessment

Purpose and objectives of health needs assessments

Global approach to health needs assessment

Community-based approaches to health needs assessment

Epidemiologically-based approach to needs assessment

Comparative approach to needs assessment

Corporate approach to needs assessment

Assessing the methods

Chapter 3: Prioritisation Stage of Health Needs Assessment

Health Needs Assessment for New Zealand

Health Funding Authority prioritisation process

National Health Committee review of the HFA process

Programme budgeting and marginal analysis

Chapter 4: Case Studies in Health Needs Assessment

Porirua City Health and Disability Report and Plan

Rapid appraisal in an urban setting: an example from the developed world

Chapter 5: New Zealand Context and Experiences

New Zealand Public Health and Disability Bill

The New Zealand Health Strategy

Placing health needs assessment policy into action

The Treaty of Waitangi

The Treaty of Waitangi from a social perspective

The significance of the Treaty of Waitangi for the health of Mori

Health needs assessment and Mori

New Zealand experiences with health needs assessment

Chapter 6: Best Practice In Health Needs Assessment

Approach, methods and content

Health Needs Assessment for New Zealand

Engagement with Mori

Chapter 7: Concepts of Need

Need for health care

Need, demand and supply

Appendix 1: The Treaty of Waitangi

Appendix 2: District Health Boards, Populations and Geographical Areas

Appendix 3: Sources of Health Information

Appendix 4: Service and Treatment Areas for Health Needs Assessments

Health Needs Assessment for New Zealand

Trends in health expenditure, 19942001

Setting objectives for needs assessment exercises

Relationship between task and activity in health needs assessment

Methods that supplement community health needs assessment

Two hypothetical models of care (eg, for coronary heart disease),

Groupings of models of care

Approaches to consultation on health care priorities

Numbers and standardised rates of avoidable hospitalisations per 10,000 1994

Programme budget matrix for the Child Health Strategy in Tayside

Top 10 suggested areas for service development and resource release,

District Health Boards, populations and geographical areas

Sources of health information in New Zealand by type, information and

Service and treatment areas for health needs assessments

Health Needs Assessment for New Zealand

Conceptual structure for the District Health Board purchasing process

The COPC cycle

Information pyramid constructed for rapid participatory appraisal

Contributions to the corporate view of local service needs

The seven steps in the process

A strategic framework for determining purchasing priorities

Health needs assessment rationale (policy)

Health needs assessment and change